A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

Abstract

Background: Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice. Methods: We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004. Results: 62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17–1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81–0.86, p = 0.78). Compared with younger patients, operative mortality was increased at ≧75 years (20 studies, OR = 1.36, 95% CI = 1.07–1.68, p = 0.02), at age ≧80 years (15 studies, OR = 1.80, 95% CI = 1.26–2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26–1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age ≧75 years (21 studies, OR = 1.18, 95% CI = 0.94–1.44, p = 0.06), at age ≧80 years (10 studies, OR = 1.14, 95% CI = 0.92–1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04–1.31, p = 0.01). Conclusions: The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged ≧75 years.

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

“…Symptomatic patients have a higher risk than asymptomatic patients (OR 1.62; p<0.0001), as do those with hemispheric versus retinal symptoms (OR 2.31; p<0.001), urgent versus nonurgent operation (OR 4.9; p<0.001), and reoperation versus primary surgery (OR 1.95; p<0.018). [174][175][176] Other rate and relative risk data for perioperative stroke or death after CEA are listed in Table 5.…”

Inhalational anesthetics as preconditioning agents in ischemic brain

“…A recent review of randomized and non-randomized trials evaluating gender and age and stroke risk following CEA concluded that operative stroke risk is increased in women independent of age [40]. While gender and age are known to alter experimental ischemic brain outcomes [41,42], few studies have examined gender and age in preconditioned brain exposed to ischemic and other types of brain injury.…”

Stroke Prevention-Surgical and Interventional Approaches to Carotid Stenosis

“…It was observed that women on medical therapy had fewer recurrent events, but higherperioperative risk, resulting in a worse surgical risk/ benefit ratio compared to men. In a meta-analysis of all published studies between 1980 and 2004, women had a significantly higher risk of perioperative stroke and death than men (odds ratio, 1.31; p<0.001) [21]. The cause for this imbalance is unclear, but the smaller size of the carotid arteries in women, relative to men, is a possible explanation.…”

“…In a review of more than 2500 CEA procedures performed in octogenarians, the combined perioperative stroke and death rate was 3.45%, which is within acceptable limits [22]. In another pooled analysis of trials of CEA for symptomatic stenosis in patients aged >75 years, benefit was higher compared to younger patients [21]. Administrative database studies have shown an increased perioperative mortality with increasing age; therefore, careful patient evaluation is mandatory when CEA is contemplated in octogenarians [23].…”