The Management of Carotid Stenoses in the Elderly
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Asymptomatic individuals with a significant carotid artery stenosis are at a higher risk of stroke. However, the optimal management strategy of elderly patients with asymptomatic carotid disease is controversial. Medical management with intensive atherosclerosis risk factor modification is the cornerstone of treatment as it decreases both the incidence of stroke and events in other vascular arterial beds (e.g., myocardial infarction). While data support invasive revascularization of carotid artery stenosis in select asymptomatic individuals, the magnitude of benefit in the elderly population beyond optimal medical treatment is less clear. This is due to a higher periprocedural/ perioperative risk of adverse events and a lower life expectancy compared to younger patients. In certain elderly patients with favorable anatomy, procedural risk, and life expectancy, carotid revascularization by endarterectomy or stenting may offer additional benefits beyond intensive medical therapy. Further clinical trials should determine whether revascularization offers benefits beyond optimal medical therapy and whether certain clinical features or non-invasive tests can select those with greater benefits.
KeywordsElderly Carotid artery stenosis Carotid endarterectomy Carotid stenting Stroke Peripheral arterial disease Atherosclerosis
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- 2.U.S. Census Bureau, Statistical Abstract of the United States. 2012. Available from: http://www.census.gov/prod/2011pubs/12statab/pop.pdf.
- 4.• Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–e220. This document provides up to date stroke statistics highlighting the continued importance and frequency of stroke in the United States. PubMedCrossRefGoogle Scholar
- 5.Silverman ME, Murray T, Lock B, Charles S, editors. The Quotable Osler. Philadelphia: American College of Physician; 2003.Google Scholar
- 8.• Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124(4):e54–e130. Intersocietal consensus statement with guideline recommendations for the treatment of asymptomatic carotid artery disease. PubMedCrossRefGoogle Scholar
- 12.Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273(18):1421–8.Google Scholar
- 14.•• Brott TG, Hobson 2nd RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23. The CREST Trial represents the most contemporary data comparing surgical endarterectomy and carotid artery stenting. In this study of 2502 patients, there was no difference in the primary endpoint of stroke, myocardial infarction or death between the endarterectomy and stenting groups. During the periprocedural period there was a higher risk of myocardial infarction in the surgical group and a higher risk of stroke in the stenting group. PubMedCrossRefGoogle Scholar
- 15.• Voeks JH, Howard G, Roubin GS, Malas MB, Cohen DJ, Sternbergh 3rd WC, et al. Age and outcomes after carotid stenting and endarterectomy: the carotid revascularization endarterectomy versus stenting trial. Stroke. 2011;42(12):3484–90. This paper explores data from the CREST Trial suggesting that patients over the age of 70 had a higher rate of the primary endpoint with carotid artery stenting compared to endarterectom which was driven by increased risk of stroke. PubMedCrossRefGoogle Scholar
- 17.•• Halliday A, Harrison M, Hayter E, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376(9746):1074–84. Ten year data from the landmark ACST Trial. Important findings include continued decreased stroke rates at 10 years with successful CEA for patients with asymptomatic carotid artery stenosis. However the magnitude of the benefit is reduced with improved contemporary medical therapies and these findings were not found in patients over 75 years old. PubMedCrossRefGoogle Scholar
- 22.• Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol. 2010;9(7):663–71. Study demonstrating improved risk stratification utilizating transcranial doppler signals to help identify which patients with asymptomatic carotid artery disease are more likely to develop a transient ischemic attack or an ipsilateral stroke. PubMedCrossRefGoogle Scholar