Carotid Intervention in the Elderly:  Who Is Old and Who Benefits?

R. Clement Darling III, MD1
[+] Author Affiliations
1The Vascular Group, Albany, New York
JAMA Surg. 2013;148(12):1152-1153. doi:10.1001/jamasurg.2013.4160.
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Antoniou et al1 provide a very well-written article on the meta-analysis and meta-regression analysis of outcomes of carotid endarterectomy (CEA) and stenting in the elderly. The conclusions are what most of us have seen in randomized prospective studies, such as the recent publication of Carotid Revascularization Endarterectomy vs Stenting Trial (CREST).2 Carotid endarterectomy fared well within the elderly when one considers stroke, transient ischemic attack (TIA), or both. However, patients undergoing CEA had a higher mortality (0.5% vs 0.4%), but the clinical significance of such a difference is doubtful. Conversely, those elderly patients undergoing carotid stenting (CAS) had a higher incidence of stroke, TIA, or both, yet there was no significant difference in mortality between young and old patients. The incidence of myocardial infarction was significantly higher in those patients undergoing CEA (2.2% vs 1.4%). Also, elderly patients had an increased risk of myocardial infarction compared with younger patients. These conclusions are not startling and are consistent with what many of us have seen in our clinical practices. One thing somewhat unusual was that the rate of myocardial infarction was higher in the elderly undergoing CAS, which is not corroborated in CREST or other randomized studies.24

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