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Original Investigation | SURGICAL CARE OF THE AGING POPULATION

Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly

George A. Antoniou, MD, PhD, FEBVS1,2; George S. Georgiadis, MD, PhD2; Efstratios I. Georgakarakos, MD, PhD2; Stavros A. Antoniou, MD3; Nikos Bessias, MD1; John Vincent Smyth, MCh, FRCS4; David Murray, MD, FRCS4; Miltos K. Lazarides, MD, FEBVS2
[+] Author Affiliations
1Department of Vascular Surgery, Hellenic Red Cross Hospital, Athens, Greece
2Department of Vascular and Endovascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
3Department of Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
4Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals, Manchester, United Kingdom
JAMA Surg. 2013;148(12):1140-1152. doi:10.1001/jamasurg.2013.4135.
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Importance  Uncertainty exists about the influence of advanced age on the outcomes of carotid revascularization.

Objective  To undertake a comprehensive review of the literature and conduct an analysis of the outcomes of carotid interventions in the elderly.

Design and Setting  A systematic literature review was conducted to identify articles comparing early outcomes of carotid endarterectomy (CEA) or carotid stenting (CAS) in elderly and young patients.

Main Outcomes and Measures  Combined overall effect sizes were calculated using fixed or random effects models. Meta-regression models were formed to explore potential heterogeneity as a result of changes in practice over time.

Results  Our analysis comprised 44 studies reporting data on 512 685 CEA and 75 201 CAS procedures. Carotid stenting was associated with increased incidence of stroke in elderly patients compared with their young counterparts (odds ratio [OR], 1.56; 95% CI, 1.40-1.75), whereas CEA had equivalent cerebrovascular outcomes in old and young age groups (OR, 0.94; 95% CI, 0.88-0.99). Carotid stenting had similar peri-interventional mortality risks in old and young patients (OR, 0.86; 95% CI, 0.72-1.03), whereas CEA was associated with heightened mortality in elderly patients (OR, 1.62; 95% CI, 1.47-1.77). The incidence of myocardial infarction was increased in patients of advanced age in both CEA and CAS (OR, 1.64; 95% CI, 1.57-1.72 and OR, 1.30; 95% CI, 1.16-1.45, respectively). Meta-regression analyses revealed a significant effect of publication date on peri-interventional stroke (P = .003) and mortality (P < .001) in CAS.

Conclusions and Relevance  Age should be considered when planning a carotid intervention. Carotid stenting has an increased risk of adverse cerebrovascular events in elderly patients but mortality equivalent to younger patients. Carotid endarterectomy is associated with similar neurologic outcomes in elderly and young patients, at the expense of increased mortality.

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Figures

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Figure 1.
Literature Search Strategy

Flow chart shows the strategy used for the literature search. CAS indicates carotid stenting; CEA, carotid endarterectomy.

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Figure 2.
Forest Plot for Carotid Endarterectomy and Stroke

Comparison of stroke rates between old and young age groups subjected to carotid endarterectomy. M-H indicates Mantel-Haenszel.

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Figure 3.
Forest Plot for Carotid Endarterectomy and Transient Ischemic Attack

Comparison of transient ischemic attack rates between old and young age groups subjected to carotid endarterectomy. M-H indicates Mantel-Haenszel.

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Figure 4.
Forest Plot for Carotid Endarterectomy and Stroke Plus Transient Ischemic Attack

Comparison of stroke plus transient ischemic attack rates between old and young age groups subjected to carotid endarterectomy. M-H indicates Mantel-Haenszel.

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Figure 5.
Forest Plot for Carotid Endarterectomy and Mortality

Comparison of perioperative mortality rates between old and young age groups subjected to carotid endarterectomy. M-H indicates Mantel-Haenszel.

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Figure 6.
Forest Plot for Carotid Endarterectomy and Myocardial Infarction

Comparison of myocardial infarction rates between old and young age groups subjected to carotid endarterectomy. M-H indicates Mantel-Haenszel.

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Figure 7.
Forest Plot for Carotid Stenting and Stroke

Comparison of stroke rates between old and young age groups subjected to carotid angioplasty and stenting. M-H indicates Mantel-Haenszel.

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Figure 8.
Forest Plot for Carotid Stenting and Transient Ischemic Attack

Comparison of transient ischemic attack rates between old and young age groups subjected to carotid angioplasty and stenting. M-H indicates Mantel-Haenszel.

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Figure 9.
Forest Plot for Carotid Stenting and Stroke Plus Transient Ischemic Attack

Comparison of stroke and transient ischemic attack rates between old and young age groups subjected to carotid angioplasty or stenting. M-H indicates Mantel-Haenszel.

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Figure 10.
Forest Plot for Carotid Stenting and Mortality

Comparison of peri-interventional mortality rates between old and young age groups subjected to carotid angioplasty and stenting. M-H indicates Mantel-Haenszel.

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Figure 11.
Forest Plot for Carotid Stenting and Myocardial Infarction

Comparison of myocardial infarction rates between old and young age groups subjected to carotid angioplasty and stenting. M-H indicates Mantel-Haenszel.

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Figure 12.
Scatterplots of the Relationship Between Year of Publication and Log Odds Ratio for Stroke

Scatterplots show the relationship between year of publication and log odds ratio for stroke (A) and mortality (B) in carotid angioplasty and stenting. aP = .003. bP < .001.

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