Age should be major factor in deciding carotid intervention

When determining which interventional method to use in patients who need carotid revascularization, a meta-analysis published online Oct. 23 in JAMA Surgery found that patient age should be a major consideration.

“It seems that CEA [carotid endarterectomy] is associated with improved neurologic outcomes compared with CAS [carotid stenting] in elderly patients, at the expense of increased perioperative mortality, whereas both procedures are associated with increased risk of adverse cardiac events in advanced age,” wrote the authors, led by George A. Antoniou, MD, PhD, of Hellenic Red Cross Hospital in Athens, Greece.

The authors performed a meta-analysis of 44 studies consisting of more than 512,000 CEA procedures and more than 75,000 CAS procedures. They found stenting associated with a higher stroke incidence in older patients compared with younger patients (odds ratio [OR] 1.56). On the other hand, rates of incident adverse cerebrovascular outcomes were similar in older and younger patients who underwent CEA (OR 0.94).

Mortality rates were higher, however, among older CEA patients (OR 1.62). Mortality rates during CAS were about the same in older and younger patients (OR 0.86). Older patients undergoing either type of procedure had a higher risk of MI (OR 1.64 in the CEA group and 1.30 in the CAS group).

The neurologic risk of CAS in elderly patients, the authors explained, may be linked to the manipulation of the wire through “unfavorable” vascular anatomy, including areas of calcification, tortuosity and abnormal aortic arch characteristics.

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

The researchers acknowledged that a major limitation of the analysis was the differing definition of elderly patients. Some studies considered elderly patients to be older than 65, while others used 80 years or older to define elderly. To account for this variability, Antoniou and his colleagues evaluated outcomes in similar age groups, which, they said, confirmed their original analyses.

But in an accompanying editorial, R. Clement Darling III, MD, of The Vascular Group in Albany, N.Y., argued that the variability in age definition poses a problem when determining which approach is best.

However, he also said these findings as well as others from past studies suggest that “CEA and CAS seem to work equally well in younger patients, in expert hands.” In the elderly of any age, “CEA has better outcomes, with low morbidity, mortality and stroke rate and remains the gold standard.”