Carotid Endarterectomy in Nonagenarians—Invited Critique

The NASCET demonstrated the highest level of absolute risk reduction for carotid endarterectomy performed in patients 75 years and older (28.9%). Operative risk also decreased with increasing age in this trial. This, together with the increased morbidity of stroke in the elderly patients, provides a rationale for studying the effectiveness of carotid endarterectomy in nonagenarian patients. The authors are to be commended for their excellent results in treating a small subset of 26 patients 89 years or older with carotid endarterectomy; these patients were essentially devoid of perioperative stroke and cardiac morbidity. One could argue that this was a relatively healthy group of very elderly patients without the usual comorbid risk factors present in the typical vascular surgery patient population. Nevertheless, many surgeons would still consider nonagenarians to be at increased risk for perioperative complications. Because the morbidity and mortality of carotid endarterectomy has been shown to be inversely proportional to surgeon and facility volume, a case could be made for operating on such a high-risk group at regionalized centers. This is particularly relevant because unusual technical difficulties, such as high carotid bifurcations, dense adherence of surrounding tissues, and looping internal carotid arteries requiring derotation, were common.