Carotid artery stenting appears associated with increased stroke in elderly

Carotid artery stenting (CAS) was associated with an increased risk of stroke in elderly patients but the mortality risk appeared to be the same as for nonelderly patients, according to a review of the medical literature published Online First by JAMA Surgery, a JAMA Network publication.

There is debate about the most appropriate treatment for carotid artery atherosclerosis and about the safety of CAS (using a stent to expand the carotid artery) and CEA (carotid endarterectomy, a procedure to remove plaque from the artery) in elderly patients, according to the study background.

George A. Antoniou, M.D., Ph.D., of the Hellenic Red Cross Hospital, Athens, Greece and colleagues reviewed the medical literature and analyzed 44 observational studies that reported data in 512,685 CEA and 75,201 CAS procedures. In general, the scientific quality of the medical literature was low, the authors report, and studies used different criteria to distinguish older from younger patients (ages 65, 70, 75 and 80).

The researchers' review suggests that while CEA had similar neurologic outcomes (stroke, transient ischemic attack or both) in old and younger patients, CEA was associated with higher mortality risk in elderly patients. Both CAS and CEA appeared to increase the risk of myocardial infarction (heart attacks) in older patients. Compared to CEA, elderly patients undergoing CAS had a higher risk of developing stroke, TIA or stroke plus TIA early after the intervention than did younger patients, according to the study.

"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," the study concludes.

Commentary: Carotid Artery Stenting Appears Associated with Increased Stroke in Elderly

In a related commentary, R. Clement Darling III, M.D., of the Vascular Group, Albany, N.Y., writes: "A major concern I have about the article by Antoniou et al is the definition of elderly. One really has to wonder what is 'elderly' since 64 percent of the trials used 80 years as the cutoff, 31 percent used 75 years, one study defined elderly as 70 years, and another study even used age 65 years."

"This inconsistent approach incorporates tremendous variation; thus it is more difficult to decide, if all things are equal, which intervention would best benefit the patient," Darling continues.

"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," the commentary concludes.