Carotid stenting appears to be associated with increased stroke in elderly patients

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A new study has found that age should be a consideration when planning a carotid intervention. The authors of the study state that there is an increased risk of adverse cerebrovascular events when carotid stenting is carried out in elderly patients when compared with younger patients (odds ratio: 1.56; 95% CI, 1.40–1.75 vs. 0.94; 95% CI. 0.88–0.99).

The study, published online first in JAMA Surgery says that there is debate about the most appropriate treatment for carotid artery atherosclerosis and about the safety of carotid artery stenting and carotid endarterectomy in elderly patients.

George A Antoniou, Hellenic Red Cross Hospital, Athens, Greece, and colleagues reviewed the medical literature and analysed 44 observational studies that reported data in 512,685 carotid endarterectomy and 75,201 carotid artery stenting procedures. In general, the scientific quality of the medical literature was low, the authors report, and studies used different criteria to distinguish older from younger patients (ages 65, 70, 75 and 80).

The researchers’ review suggests that while carotid endarterectomy had similar neurologic outcomes (stroke, transient ischaemic attack or both) in old and younger patients, endarterectomy was associated with higher mortality risk in elderly patients (0.5 vs. 0.4, respectively, but the clinical significance of the difference is doubtful, according to an accompanying commentary).

Both endarterectomy and stenting appeared to increase the risk of myocardial infarction in older patients (odds ratio: 1.64; 95% CI, 1.57–1.72 vs. 1.30; 95% CI, 1.16–1.45, respectively). Compared to endarterectomy, elderly patients undergoing stenting had a higher risk of developing stroke, transient ischaemic attack or stroke plus transient ischaemic attack early after the intervention than did younger patients, according to the study.

“The results of the present analysis suggest that careful consideration of a constellation of clinical and anatomical factors is required before an appropriate treatment of carotid disease in elderly patients is selected,” the study concludes.

In the related commentary, R Clement Darling III of the Vascular Group, Albany, USA, writes: “A major concern I have about the article by Antoniou et al is the definition of elderly. One really has to wonder what is ‘elderly’ since 64% of the trials used 80 years as the cut off, 31% used 75 years, one study defined elderly as 70 years, and another study even used age 65 years.”

“This inconsistent approach incorporates tremendous variation; thus it is more difficult to decide, if all things are equal, which intervention would best benefit the patient,” Darling continues.

“The bottom line is, carotid endarterectomy and carotid artery stenting seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), endarterectomy has better outcomes with low morbidity, mortality and stroke rate and remains the gold standard,” the commentary concludes.

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