Assessment of long-term survival and stroke after carotid endarterectomy and carotid stenting in patients older than 80 years

Abstract

Objective: The objective of this study was to analyze preoperative risk factors affecting long-term survival and the occurrence of stroke in patients older than 80 years undergoing either carotid endarterectomy (CEA) or carotid artery stenting (CAS) for carotid stenosis.

Methods: Data of all consecutive patients treated from January 1999 to December 2017 were retrospectively reviewed and outcomes analyzed. Kaplan-Meier analysis was used to estimate long-term survival and the risk of stroke for both groups. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality and long-term stroke for patients in the presence of selected comorbidities, including preoperative symptoms, coronary artery disease, chronic renal failure, atrial fibrillation (AF), hypertension, diabetes mellitus, and dyslipidemia. A P value <.05 was considered statistically significant.

Results: A total of 473 patients older than 80 years (298 men [63%]) underwent either CEA (n = 178) or CAS. At 30 days, one patient died in the CEA group of unrelated causes; no deaths were recorded after CAS (0.6% vs 0%; P = .18). At 5 years, survival was 67.6% ± 4.9% after CEA and 90.2% ± 2.3% after CAS (P < .0001). The main cause of death after CEA and CAS was a neoplasm. Estimated freedom from any stroke at 5 years was 97.3% ± 0.5% after CEA and 93.2% ± 1.2% after CAS (P = .07). The presence of preoperative AF significantly affected long-term mortality after CAS (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.34-1.98; P = .04) as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF was the only factor that significantly affected the occurrence of long-term stroke after both CAS (HR, 2.28; 95% CI, 1.86-5.63; P = .001) and CEA (HR, 3.45; 95% CI, 2.29-8.19; P = .005).

Conclusions: Both CEA and CAS showed low 30-day mortality and any-stroke rates in patients older than 80 years. In the long term, survival was significantly better after CAS; however, deaths after CEA and CAS were mainly unrelated to the procedure. No significant differences were recorded in the occurrence of any stroke in the long term. The presence of preoperative AF significantly affected long-term survival after CAS as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF also significantly affected long-term risk of stroke after both CAS and CEA.

Keywords: Carotid endarterectomy; Carotid stenting; Elderly; Survival.