March 25, 2010—In Catheterization and Cardiovascular Interventions, Arthur Grant, MD, et al have published findings from a study of the safety and efficacy of carotid artery stenting (CAS) in the very elderly (2010;75:651–655).
The background of the study is the emergence of CAS as an alternative to carotid endarterectomy in patients at high risk for complications from surgery. The very elderly (aged ≥ 80 years) are one subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% was reported in very elderly patients during the roll-in phase of CREST (Carotid Revascularization Endarterectomy Versus Stent Trial).
In this analysis, the investigators reported on a large clinical series of CAS with independent neurological assessment in the very elderly. Between 1994 and 2008, a consecutive series of 418 CAS patients (≥ 80 years of age) were treated at four high-volume centers with extensive CAS experience. Independent neurologic assessment was performed after CAS procedures. Thirty-day follow-up information was available for 389 patients.
The investigators reported that the average age of patients in the study was 83.2 ± 2.8 years, most patients were men (63.2%), and the target lesion carotid stenosis was asymptomatic in two-thirds of patients (68.2%). The majority of patients treated with CAS had a history of coronary artery disease (74.4%), hypertension (87.8%), and dyslipidemia (71.1%). One-third (30.1%) were diabetic, and more than half (56.5%) were current or former smokers. Embolic protection devices (EPDs) were used in 78.7% of cases, with the unavailability of EPDs at the time of CAS being the most common reason for not using them. The overall 30-day incidence of stroke and death was 2.8% (11/389). The cumulative incidence of major cardiovascular events (stroke, death, or myocardial infarction) during that time period was 3.3% (13/389).
The investigators concluded that this large series of CAS with independent neurologic assessment is convincing evidence that the very elderly can safely undergo CAS with stroke and death rates comparable to younger patients. The key to obtaining these excellent results is that CAS must be performed by high-volume, experienced operators who exercise restraint regarding patient selection.
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