Carotid Artery Stenting Riskier in Octogenarians

By Janice Rosenberg

CHICAGO -- Carotid artery stenting in patients 80 years old or older is associated with heightened periprocedural risk and should be cautiously considered, according to research presented by Stephen F. Stanziale, M.D., at the Vascular Annual Meeting.

Carotid endarterectomy is considered the most effective treatment for stroke prevention in patients with high-grade symptomatic or asymptomatic carotid artery disease and is one of the most commonly performed peripheral vascular procedures. However, in specific clinical settings, carotid artery stenting (CAS) has emerged as an alternative therapy to endarterectomy.

Recent technological innovations--including crush-resistant stents that keep arteries open better than before and embolic protection devices that trap plaque, debris, and blood clots that break off within the vessel during the procedure--have improved overall safety.

Previous reports on the safety of CAS in very elderly patients offered conflicting results. Dr. Stanziale and his colleagues at the University of Pittsburgh Medical Center and the Pittsburgh Vascular Institute reviewed the records from a prospective database of 382 carotid stent patients who underwent the procedure between June 1996 and March 2004 to determine in a modern series if octogenarians are at increased risk for adverse outcomes after carotid stenting.

Of those patients, 102 were symptomatic, and 280 were asymptomatic. All the procedures were performed at a single institution by three interventionalists. All patients were examined by an independent neurologist and received self-expanding stents. Distal embolic protection was used in 208 patients. Eighty-seven patients were aged 80 years or older.

Findings of this study indicate that even with the latest improvements, CAS continues to pose higher risks of adverse events for octogenarians than for younger patients. The octogenarians had higher rates of stroke (8.0%) or major adverse events--including stroke, heart attack, and death (9.2%)--either during or immediately after the procedure than did younger patients (2.7% and 3.4%, respectively). At 1-year follow-up, patients older than 80 years continued to have more major adverse outcomes, including stroke.

"In our study, octogenarian status had a significant association with stroke and death over a 1-year follow-up," Dr. Stanziale said. "Randomized clinical data are necessary to confirm our findings and to determine the appropriateness of carotid artery stenting in octogenarians."

Caution should be the rule in stenting octogenarians, said Dr. Stanziale, especially in asymptomatic patients, for whom the proven benefit is not as great as for symptomatic patients.