Carotid Artery Stenting Appears to Increase Stroke
Risk in Elderly
Risk of stroke higher but risk of death about same as
for nonelderly; what is elderly?
Oct. 23, 2013 - 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
JAMA Surgery, a JAMA Network publication. A commentary in
the same issue asks what age is “elderly.”
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
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
“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.
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
“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
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