Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 190-194, March 2008

Carotid Reconstruction in Nonagenarians: Is Surgery a Viable Option?

Cedars-Sinai Medical Center, Division of Vascular Surgery, Los Angeles, CA

Article Outline

Because of limited longevity and perceived increased perioperative risk, the optimal treatment of significant carotid stenosis in nonagenarians is controversial. This study was conducted to evaluate our results in this demographic group. A retrospective review was performed of carotid endarterectomies (CEAs) done in nonagenarians at Cedars-Sinai Medical Center between 1996 and 2006. During this period, a total of 2,038 CEAs were performed on patients of all ages. Data abstracted included demographics, patient risk factors, indications for surgery, perioperative complications, and survival. Fifty-three (2.8%) CEAs were performed as the primary procedure on 49 patients aged 90 or greater during the study period. Of these patients, 11 (22.4%) had diabetes, 38 (77.5%) had hypertension, and 31 (63.3%) had coronary artery disease. Eleven patients (22.4%) had a history of smoking, and there were no current smokers. Renal disease was present in three (6.1%) patients, one of whom was dialysis-dependent. The median length of stay was 2 days with a range of 1 to 24 days. Five patients (10.2%) required the intensive care unit following surgery. There were no postoperative strokes, and none of the patients had suffered ipsilateral stroke during follow-up. One patient (1.8%) had a perioperative myocardial infarction. One patient died in the perioperative period (1.8%). The 1-month stroke and mortality results did not differ significantly from those in patients under the age of 90, 0.3% and 0.4%, respectively (p = nonsignificant by Fisher's exact test). Using Kaplan-Meier life-table analysis, the 1- and 5-year survival rates were 84 ± 5% and 33 ± 9%, respectively. Our study demonstrates that in a group of well-selected nonagenarians, CEA is a safe procedure with acceptable perioperative morbidity.

 

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Introduction 

Both the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) excluded patients over the age of 80 from randomization.1, 2 Advocates of carotid stenting have suggested that all patients over the age of 80 with significant carotid lesions should be treated with percutaneous intervention. Nearly 20% of patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study were classified as high-risk because of age over 80.3 However, several retrospective studies have shown the safety of carotid endarterectomy (CEA) in octogenarians.4, 5, 6, 7, 8, 9 Because of presumed increased risk and unclear survival benefit, operating on nonagenarians remains controversial. In a 2005 report by Durward et al.,10 26 primarily symptomatic patients aged 89 or older underwent CEA with no perioperative cerebral or cardiac morbidity. In that same year, Teso et al.11 reported an increase in mortality in nonagenarians undergoing CEA. In light of the unresolved controversy of endarterectomy versus stenting, we have reviewed our experience with CEA in nonagenarians.

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Methods 

This study was a retrospective review of all patients over the age of 89 who underwent CEA from January 1996 to December 2006. During these 11 years, a total of 2,038 CEAs were performed on patients of all ages. Fifty-three patients over age 89 underwent 57 CEAs during the study period (2.8%). Four of these patients were excluded from further analysis because they underwent CEA just prior to other major operations (fixation of hip fracture, coronary bypass, and two major abdominal procedures). Demographic and follow-up information was obtained from hospital records and the clinic charts of both the surgeon and primary physician.

Of the remaining 49 patients, 25 were women and 24 men. Four patients had staged bilateral operations. All CEAs were performed under general anesthesia. We routinely utilized a shunt and patched the arteriotomy with Dacron® (DuPont, Wilmington, DE). In the asymptomatic patient population, carotid stenosis was determined solely by duplex scans performed at the hospital-based vascular lab. Patients referred with duplex scans, magnetic resonance (MR), or computed tomographic (CT) angiograms performed outside of the hospital imaging department had corroborative studies performed at our institution. Symptomatic patients had duplex scans at the hospital vascular laboratory. When the degree of stenosis was only moderate (50-69%), MR or CT angiography was utilized. Duplex scan criteria included internal carotid:common carotid artery peak systolic velocity ratios, peak systolic velocities, end diastolic velocities, and pattern recognition. These criteria have been corroborated in our vascular laboratory to correspond to NASCET standards. Asymptomatic patients had ≥80% stenosis and symptomatic patients had ≥70%. Two procedures were for recurrent stenosis. Demographic variables recorded were presence of hypertension (HTN), diabetes mellitus, coronary artery disease (CAD), renal disease, and smoking history (Table I). We defined myocardial infarction as the presence of troponin I elevation above our laboratory normal of <0.1 and/or electrocardiographic changes consistent with myocardial ischemia. Many patients in our study group were admitted several days prior to surgery due to symptoms from a stroke or transient ischemic attack. Length of stay was defined by the number of postoperative hospital days. Date of death was determined from the Social Security Death Index.12

Table I. Patient demographic information
Medical historyNumber of patients (%)
Hypertension38 (78)
Coronary artery disease31 (63)
Diabetes mellitus11 (22)
Renal disease3 (6)
Dialysis-dependent1 (2)
History of smoking11 (22)
Current smokers0 (0)

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Results 

A little over half (55.1%) of our study population underwent surgery for asymptomatic carotid artery stenosis of >80%. The remaining 44.9% had either ipsilateral stroke (24.5%), transient ischemic attack (10.2%), or amaurosis fugax (10.2%). In comparison, 73% of patients under the age of 90 had CEA for asymptomatic disease. The average age at time of surgery was 91.8 ± 1.5 years, with a range of 90-96 years. Survival for the 49 patients was estimated using the Kaplan-Meier method. Thirty-day survival was 98 ± 2.1%. One patient died in the perioperative period from sepsis secondary to aspiration. The 1-, 3-, and 5-year survival estimates were 84 ± 5%, 52 ± 8%, and 33 ± 9%, respectively (Table II). Median survival was 3.5 years (95% confidence interval 1.9-5.7 years). There was no significant difference in survival rates between symptomatic and asymptomatic patients (Fig. 1, Table III).

Table II. Survival estimates
30 days98 ± 2%
180 days97 ± 3%
1 year84 ± 5%
2 years64 ± 7%
3 years52 ± 8%
5 years33 ± 9%
Table III. Survival ± SE% by symptom status
TimeSymptomaticAsymptomatic
0100%100%
30 days96 ± 4%100%
180 days96 ± 4%96 ± 4%
1 year85 ± 8%84 ± 7%
2 years57 ± 12%70 ± 10%
3 years40 ± 12%64 ± 10%
4 years40 ± 12%43 ± 12%
5 years33 ± 11%32 ± 13%
6 years33 ± 11%21.± 12%

SE, standard error.

Complication rates were low in this patient population. There were no ipsilateral strokes seen during the perioperative period or during long-term follow-up. One patient (1.8%) had a perioperative myocardial infarction. This patient required no procedural intervention by cardiology and was managed medically. The combined 30-day stroke and mortality rates for the nonagenarians (0% and 1.8%) did not differ from those for patients under age 90 (0.3% and 0.4%) (p = 0.21 by Fisher's exact test).

The average postoperative length of stay was 3.4 ± 4.3 days (median 2, range 1-24). Fifteen patients (30.6%) stayed only 1 postoperative day. Thirteen (26.5%) stayed 2 postoperative days. Intensive care unit (ICU) observation was needed in five patients (10.2%). Three patients (6.1%) had a postoperative hematoma that required surgical evacuation. All three were then observed in the ICU for 24 hours following the second surgery. The one patient who suffered a postoperative myocardial infarction was observed in the ICU for administration of intravenous ß-blockers for a 24-hour period as well. The final patient who received ICU care was the patient who ultimately died within 30 days of surgery. This patient had CEA for a severe recurrent stenosis and a prolonged hospital course due to repeated silent aspiration. After several weeks of hospital care and speech therapy, she had a significant aspiration episode, which required intubation and ICU transfer.

A Cox proportional hazards regression model was used to assess comorbidities associated with a decrease in long-term survival. Of these variables (age, diabetes mellitus, HTN, CAD, renal disease, smoking), only increasing age was found to be associated with decreased long-term survival (p = 0.03). Although results were not statistically significant, there were trends toward decreased long-term survival (p = 0.09) and increased length of stay (p = 0.13) associated with presence of CAD (Fig. 2, Table IV).

Table IV. Survival ± SE% by CAD status
TimeCADNo CAD
0100%100%
30 days97 ± 3%100%
180 days97 ± 3%94 ± 4%
1 year82 ± 8%89 ± 8%
2 years52 ± 10%82 ± 9%
3 years47 ± 10%60 ± 13%
4 years33 ± 10%60 ± 13%
5 years22 ± 9%60 ± 13%
6 years15 ± 9%40 ± 18%

SE, standard error.

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Discussion 

The results of this study demonstrate that CEA can be performed safely in nonagenarians with well-managed comorbidities. The risks of perioperative death, stroke, and myocardial infarction are similar to those for younger patients. The presence of preoperative neurological symptoms did not influence operative risk. Although we are less likely to offer CEA to asymptomatic patients over the age of 89 than younger patients, our fundamental guideline for treatment involves an assessment of the likelihood of a good quality of life 5 years from the time of surgery. All of these patients were highly functional, independent individuals without major organ dysfunction. Based on the 2003 data from the National Vital Statistics Report, the average life expectancy for patients 90-95 years old is 4.8 and 3.5 years, respectively.13 Since the risk of stroke is greatest within the first 1-2 years after onset of symptoms, we are more liberal in recommending surgery after minor stroke, transient ischemic attack, or amaurosis fugax in this age group. There is an increase in disability following a stroke with increasing age10 that justifies an aggressive approach.

Beginning in 1989 we made a transition from routine ICU observation to specialized floor care.14 Although routine ICU admission and monitoring for these elderly patients has been advocated,5 we have not found that intensive observation is warranted solely based on the patient's age.15 Nurses on a ward with a concentrated vascular population are more cognizant of postoperative complications such as subtle neurological changes or neck hematomas than the average ICU nurse caring for a broad spectrum of surgical patients. Indication for ICU admission and monitoring for nonagenarians in this environment should mirror that for younger patients for this surgery as their complication rates are similar.

There are conflicting data on the risk of CEA in elderly patients. Medicare data from the 1980s reflect a three- to fourfold increase in morbidity and mortality in patients over the age of 75 or 80 years.16, 17 However, multiple single-institution series have shown that CEA can be performed in the elderly without an increase in risk.3, 5, 6, 9, 18, 19, 20, 21, 22 Most studies on the elderly have focused on patients over the age of 80. There are few data on the risk of CEA in nonagenarians, a rapidly growing segment of our population. Durward et al.10 reported on 26 predominantly symptomatic patients 89 years or older who underwent CEA. There were no perioperative cerebral ischemic or cardiac events, with a mean hospital stay of 2 days. In a report by Teso et al.11 including 64 nonagenarians, these patients were found to have increased length of hospital stay (7.3 days) and perioperative mortality (3.2%). The length of stay and mortality seen in younger patients were 1.2 days and 0%, respectively. Also in this study, the greatest morbidity and mortality rates were seen in symptomatic patients (14% of their nonagenarian population).

Carotid stenting has been advocated as a less invasive and potentially less morbid means of cerebral revascularization in the elderly.23, 24, 25 In the SAPPHIRE trial, stenting was associated with significantly less cardiac morbidity than CEA in high-risk patients, including those over age 80 years. In contrast, Hobson et al.8 reported a markedly increased risk of complications in elderly patients during the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) lead-in phase. The 30-day risk of stroke or death in patients under age 80 years was 3.2% compared to 12.1% in patients over the age of 80. More recently, in a report by Russell et al.,26 the combined stroke, death, and myocardial infarction rate for patients over age 80 was 10.8% compared to 1% in those under 80. These reports have tempered enthusiasm for stenting in the elderly except for recurrent disease. The one death in our experience would currently be treated with a stent. This patient, who had a CEA in 2000, was one of the three individuals in our series with significant recurrent stenosis. We believe that stenting of early recurrent lesions is of relatively low risk and, in retrospect, would be the preferred treatment in these elderly patients.27

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Conclusion 

CEA can be performed with low complication rates in nonagenarians. The reasonable survival of these patients warrants an aggressive approach. CEA remains the standard of care as preliminary data from randomized trials of carotid artery stenting suggest that there is a prohibitive complication rate in patients over age 80.

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We thank James Mirocha, senior biostatistician for the Research Institute at Cedars-Sinai Medical Center, for his assistance with the statistical analysis of our data.

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References 

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PII: S0890-5096(08)00002-2

doi:10.1016/j.avsg.2007.12.001

Annals of Vascular Surgery
Volume 22, Issue 2 , Pages 190-194, March 2008

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