Aaron Tansy, MD

Carotid endarterectomy (CEA) is standard therapy for symptomatic internal carotid stenosis. However, benchmark trials that demonstrated the procedure’s efficacy did not enroll patients > 80 years leaving unanswered whether CEA may be a favorable treatment in this cohort as well. Now in an upcoming issue of Stroke, Kumar Rajamani and colleagues provide a first attempt to address this question: a retrospective analysis of outcomes in elderly patients who underwent CEA.

The investigators culled data from the CARE© Registry, a multi-hospital, clinical procedures registry, and evaluated the effects of age (stratified into 4 groups: 70-74, 75-79, 80-84, and >/85) and symptomatic status (asymptomatic or symptomatic) on primary composite outcome (in-patient stroke/death/MI), singular morbidities, and mortality following CEA. A total of 4149 patients underwent CEA, 1/3 of which were symptomatic. Analysis revealed with increasing age came significantly increasing risk of the composite outcome and mortality after CEA with those >/85 years at highest risk. In addition, increased age (>75) increased risk of mortality for those in the asymptomatic sub-group. Conversely, increased age did not alter risk for mortality in the symptomatic group or for morbidity in either sub-group.

Although not reflective of all hospitals performing CEA’s, this study reveals a few key facts about current CEA practice generally in the US. For one, the vast majority of patients > 70 years currently undergoing CEA have asymptomatic carotid stenosis. Further, this subgroup appears at highest risk for CEA-related death independent of complications such as MI or stroke. Lastly, those oldest who undergo CEA are most likely to suffer complications or death.

Although in the original trials it was not superior to medical therapy (aspirin) for stroke risk reduction in asymptomatic patients, CEA did provide non-significantly better benefit long-term prompting its consideration in younger patients whose long-term risk of stroke was considered higher than their long-term risk of death. Given that standard medical therapy today has supplanted aspirin with more effective antiplatelet agents and high-dose statins, it is now even less likely that CEA provides significant benefit over current medical therapy especially in the elderly. Thus, while only one retrospective evaluation, this study raises an important question for which we should give pause and concern: when we already have effective medical therapies in place, should we continue to engage in a surgical practice on asymptomatic patients that research, to this point, has yet to support as clearly beneficial and, even more worrisome, now supports only as harmful?