Association Between Age and Risk of Stroke From Carotid Endarterectomy and Carotid Stenting

Study Questions:

For patients with symptomatic carotid disease, what is the impact of age on outcomes after endarterectomy versus stenting?

Methods:

This study is a meta-analysis of patients with symptomatic carotid disease who were enrolled in the following trials that compared carotid endarterectomy (CEA) with carotid stenting (CAS): EVA-3S, SPACE, ICSS, and CREST. The primary outcome was any stroke or death in the periprocedural period (randomization to 120 days after randomization) and ipsilateral ischemic stroke in the post-procedural period (after 120 days). The authors focused on the effects of age, classified as <60, 60-64, 65-69, 70-74, 75-79, and >80 years, on outcomes. The analyses included Kaplan-Meier methods as well as Cox proportional hazards techniques, which were used to estimate hazard ratios (HRs), after adjusting for trial.

Results:

There were 4,754 patients randomized to CEA or CAS across the four studies. There was a similar balance of vascular risk factors between the various age groups, with the exception of older patients being less likely to smoke. For patients randomized to CEA, there was no difference in the risk of periprocedural stroke or death across the age strata (HRs, 0.81-1.29; p = 0.34). For patients randomized to CAS, the risk of periprocedural stroke or death increased with age: 2.1% in the <60 group compared with ~11% for those ≥70 years (p < 0.0001). While there was no difference between CEA and CAS in the event rate for patients <69 years, patients ≥70 years who had CAS had a higher risk of stroke or death than those who had a CEA. There were 4,289 patients included in the post-procedure analyses and 90 (2.3%) had an ipsilateral stroke. The risk of post-procedural ipsilateral stroke did not differ between the age strata in the CEA or CAS groups.

Conclusions:

While there do not appear to be age differences in the risk of ipsilateral stroke after CEA or CAS, in older patients, the periprocedural risk of CAS is higher than CEA.

Perspective:

While CAS was initially thought to be less invasive and potentially safer than CEA, this and other analyses have not supported this assumption. The mechanism that underlies the increased risk of CAS in elderly patients is not clear. Increased vessel tortuosity or a higher burden of atherosclerotic disease that can embolize during the procedure have been proposed. Additional research is necessary to determine which factors predict stroke or death in older patients undergoing CAS. It is unclear how the results from this study generalize to routine clinic practice where the event rates have been higher for both procedures than the event rates in clinical trials. Until additional studies are available to help determine which older patients are at lower risk from CAS, it is reasonable to favor CEA in patients ≥70 years with symptomatic carotid disease.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Interventions and Vascular Medicine, Smoking

Keywords: Aged, Cardiac Surgical Procedures, Carotid Artery Diseases, Embolism, Endarterectomy, Carotid, Geriatrics, Risk Factors, Smoking, Stents, Stroke, Treatment Outcome, Vascular Diseases


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