Clinical Significance of Carotid Endarterectomy and Carotid Artery Stenting in Older Patients Over 80

Abstract

As the average life expectancy increases, neurosurgeons are likely to encounter patients aged 80 years and above with carotid stenosis; however, whether old age affects clinical post-treatment outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) remains inconclusive. Thus, this study aimed to evaluate the outcomes following CEA or CAS in patients aged 80 years and above. This study included older over 80 years (n = 34) and younger patients (<80 years; n = 222) who underwent CEA or CAS between 2012 and 2022. All of them were followed up for a mean of 55 months. All-cause mortality, the incidence of vascular events, ability to perform daily activities, and nursing home admission rates were assessed. During follow-up periods, 34 patients (13.3%) died due to coronary artery disease, malignancy, and pneumonia, and the incidence was significantly higher in the elderly group than in the younger group (P = 0.03; HR, 3.01; 95% CI, 1.53-5.56). The incidence of vascular events did not differ between the older group (29.5%) and the younger group (26.9%, P = 0.58); however, the incidence was significantly higher in patients with high-intensity plaques than in those without that (P = 0.008; HR, 2.83, 95%CI, 1.27-4.87). The decline in the ability to perform daily activities and increased nursing home admission rates were high in elderly patients (P < 0.01). Although the mortality rate was higher in the elderly group, subsequent vascular events were comparable to that in the younger group. The results suggest that CEA and CAS are safe and useful treatments for carotid stenosis in older patients, especially to prevent ipsilateral ischemic stroke.

Keywords: carotid artery stenting; carotid endarterectomy; carotid stenosis; long-term follow-up; older patients.

Fig. 1

This chart suggested this study's patient selection flow. Finally, 256 patients who underwent CEA/CAS with over 6 months of follow-up were included in this study.

Fig. 2

A: Kaplan-Meier survival plot for both age patients following CEA/CAS. The outcomes significantly differed between the younger and older patients (log-rank test, P = 0.03). B: Pie chart depicting the causes of death during the follow-up period. The most frequent cause of death was acute coronary syndrome (26.5%), followed by malignant neoplasm (23.5%), pneumonia (14.7%), and renal failure (8.8%).

Fig. 3

A: The Kaplan-Meier plot of the probability of vascular events in both patient groups following CEA/CAS. There were no significant differences between the younger and elderly patients (log-rank test, P = 0.58). B: The Kaplan-Meier plot of the probability of vascular events in those with high-intensity and iso-intensity plaques. There were significant differences between the patients with iso-intensity and high-intensity plaques (log-rank test, P = 0.008).

Fig. 4

Bar graphs showing the proportions of patients who could not perform activities of daily living and nursing home admissions in both age groups. Twenty-eight patients (10.7%) could not walk, 38 patients (14.8%) could neither get dressed nor bath independently, and 8 patients (3.2%) were admitted to a nursing home. The proportions of patients who could neither walk nor get dressed and bath independently were significantly higher in the older patients than in the younger patients, including the proportion of patients admitted to a nursing home.