Carotid Endarterectomy in Nonagenarians

Abstract

Hypothesis:The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial demonstrated that a greater benefit from carotid endarterectomy (CEA) was seen in elderly compared with younger patients. However, no patients older than 89 years were included in either study. We hypothesized that CEA is safe and effective in patients 89 years and older.Design and Setting: This is a retrospective review of 3 neurosurgeons' CEA experience with nonagenarian patients.Participants and Interventions: Of our 1800 patients who underwent CEA, 26 were 89 years or older. Twenty-three patients had had cerebral ischemic symptoms (unilateral hemispheric symptoms in 21 and 2 dizzy spells associated with bilateral high-grade stenosis). Cerebral angiography was performed in 3 patients. Twentythree patients underwent noninvasive imaging. Four patients had bilateral high-grade stenosis and underwent staged bilateral CEA. All procedures were performed after the induction of general anesthesia with electroencephalographic (and, more recently, transcranial Doppler) monitoring and etomidate-induced burst suppression for cerebral protection during cross-clamping.Results: Unusual technical difficulties were frequently noted, including high bifurcations, looping rotated internal carotid arteries, and marked adherence of surrounding soft tissues. In 3 of the 30 procedures, a shunt was used. There were no perioperative cerebral ischemic or cardiac events. The mean hospital stay was 2 days. One patient had a transient vocal cord paresis. Twentytwo patients were alive and well 24 months following the procedure. Four patients died of non-stroke-related causes.Conclusions: Carotid endarterectomy was successfully performed without perioperative cerebral or cardiac complications in our series of 26 patients 89 years and older undergoing 30 CEAs. Extrapolating from reported results from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial, we believe CEA should be considered in nonagenarian patients with high-grade symptomatic carotid stenosis who are otherwise well medically. Our recommendations are less certain in the case of asymptomatic disease.

Commentary

“…These results reported by Durward et al 4 are certainly commendable and support my own bias that carotid endarterectomy should not be withheld, when otherwise indicated, simply on the basis of age alone. In our own experience with 182 carotid endarterectomies performed among 167 octogenarians (mean age, 83 years; range, 80-93 years), my colleagues and I found that the early postoperative results were as good for properly selected octogenarians as they were for younger patients.…”

“…3 Durward et al present a series of 26 patients, with a mean age of 91 years, who underwent 30 carotid endarterectomies for severe carotid stenosis. 4 The authors specify that all the patients were leading independent lives at the time of surgical consideration. The patients were accumulated over a 10-year period, and most procedures were done for focal or nonfocal neurologic symptoms, although 7 procedures were done for asymptomatic stenoses, 6 of which (86%) were progressive.…”

Postendarterectomy Mortality in Octogenarians and Nonagenarians in the USA from 1993 to 1999

“…Only a few studies reported rates for nonagenarians. In-hospital mortality was 3.1% among 64 patients in one study [35], and 30-day mortality rates ranged from 0 to 6.3% [34,36] in studies of 26 and 16 patients, respectively. Many of these reports combined multiple years of data and did not describe changes over time.…”

“…Limited data have been published on the long-term outcomes following CEA in nonagenarians. One study of 26 patients aged ≥90 years found a 15% 2-year mortality rate [36]. Data from the US National Vital Statistics Report show that the average 80-year-old in the USA has a 5-year survival of 70%, and the average 90-year-old has a 5-year survival of 42% with life expectancies of 9 and 5 years, respectively [46].…”

“…The 5-year mortality rate for patients >80 years of age is estimated between 25 and 55%, based on data from 3 international and 1 US study, each with fewer than 200 patients [14,15,19,20]. Thirty-day mortality rates in nonagenarians range from 0 to 6.3% with a 2-year mortality of 15% [34,35,36]. These estimates are based on studies with small numbers of patients drawn from single hospitals, statewide samples or small surgical groups.…”