October 24th, 2013
Surgery Preferable to Stents in Elderly People with Carotid Disease
Larry Husten, PHD
Age should play an important role in choosing a revascularization procedure for people with blocked carotid arteries, according to a new paper published in JAMA Surgery. Carotid endarterectomy surgery (CEA) is preferable to carotid artery stenting (CAS) in elderly people; for younger patients, the two revascularization procedures are broadly similar.
George Antoniou and colleagues analyzed data from 44 studies containing more than half a million CEA and 75,000 CAS procedures. In the CAS group, when compared to younger patients, elderly patients were at increased risk for stroke (odds ratio 1.56,CI 1.40-1.75). In the CEA group, the stroke results were “equivalent” in the older and younger groups (OR 0.94, CI 0.88-0.99). In the CEA group there was a small but statistically significant increase in the mortality rate in the older group compared with the younger group (0.5% versus 0.4%, OR 1.62, CI 1.47-1.77). No significant difference in mortality between the older and younger groups emerged in the CAS group. In both the CAS and the CEA groups, increased age was associated with a greater risk of adverse cardiac events.
The authors pointed out that over the course of time the differences in outcome between young and old patients has diminished in the CAS group, while remaining stable in the CEA group. They said the finding may be attributed to the learning curve and to improved CAS techniques. But the overall differences in the CAS group, they speculated, may be due to the more challenging anatomy in elderly patients.
The findings, write the authors, “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…. CEA is associated with improved neurologic outcomes compared with CAS 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.”
In an accompanying editorial, R. Clement Darling expresses concern over the definition of the term “elderly,” since the cutoff in the studies varied from 80 down to 65. But whatever the definition, he concludes, “the bottom line is, CEA and CAS seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), CEA has better outcomes with low morbidity, mortality, and stroke rate and remains the gold standard.”
This meta-analysis reinforces data from the seminal CREST trial (http://www.nejm.org/doi/full/10.1056/NEJMoa0912321#t=article) which demonstrated:
“[…] an interaction between age and treatment efficacy was detected (P=0.02) (Figure 2B and 2C), with a crossover at an age of approximately 70 years; carotid-artery stenting tended to show greater efficacy at younger ages, and carotid endarterectomy at older ages.”
So, to answer Dr Darling’s question, 70yo would appear to be the definition of elderly in the best randomized trial data we have on this subject.
The NIH has funded a 10-year outcomes study of the CREST population, so it will be interesting to see how durable the CAS results were vis a vis CEA. This could further influence the decision to pursue one treatment modality over the other.
Of course, PCI is always evolving and newer techniques may be helping to close the gap between CAS and the gold standard CEA.