Carotid endarterectomy in the asymptomatic elderly: a systematic review of literature

Abstract

Asymptomatic carotid stenosis (ACS) carries a 4.7% risk of ipsilateral stroke if left untreated. Carotid endarterectomy (CEA) is a surgical intervention that has demonstrated efficacy in reducing stroke risk among symptomatic elderly. However, literature on its efficacy in preventing stroke in patients with ACS remains limited. Our systematic review summarizes evidence on the safety and efficacy of CEA in the asymptomatic elderly.PubMed and Scopus were searched to identify articles that described outcomes after CEA for ACS in patients aged ≥ 65 years old. Articles that did not report outcomes specific to the asymptomatic elderly were excluded. Outcomes of interest were technical success, stroke, death, myocardial infarction and post-operative complications. The Newcastle Ottawa Scale (NOS) was used to perform a qualitative assessment for risk of bias and studies with NOS ≥ 6 were considered high quality. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.After a title and abstract screen, followed by a full-text review, 7 studies reporting outcomes in 76,404 patients were included. Five studies were retrospective and two were prospective. Among studies that reported criteria for intervention in ACS patients, 2 studies performed CEA for 70% stenosis and one performed CEA for 60% stenosis. One study reported outcomes for all ranges of stenosis (mild: 0-50%, moderate: 50-79% and severe: 80-99%). Clinical outcomes varied among included studies, with rates of death stroke and myocardial infarction ranging from 0.39 to 6.1%, 0.5-1.2% and 0.9-3%, respectively.The decision to perform CEA in patients with ACS is made after outweighing risks and benefits of surgery based on various factors like age, comorbidities and frailty. At present, evidence is largely limited to retrospective studies that utilized nationwide databases. Prospective studies and randomized controlled trials could help characterize the risk of CEA in this cohort.

Keywords: Asymptomatic; Carotid endarterectomy; Carotid stenosis; Elderly.