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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
Giornale Italiano di Chirurgia Vascolare 2001 June;8(2):87-96
language: English, Italian
Carotid endarterectomy in octagenarians
Grego F., Zaramella M., Antonello M., Bonvini S., Alfò K., Deriu G. P.
From the Vascular Surgery Clinic, University of Padua, Padua, Italy (Chief: Prof. G. P. Deriu)
Background. The risk for developing stroke increases with advancing age, peaking over age 80. In elderly patients, carotid endarterectomy may provide prophylaxis against stroke. However, older patients are already at greater risk for perioperative mortality and morbidity, and a careful selection must be made when choosing elderly patients who are fit enough to undergo carotid endarterectomy. In our department the age limit for carotid endarterectomy has been progressively extended over the past years. The aim of this study was to carry out a retrospective analysis of patients undergoing carotid endarterectomy in the last four years and to compare patients who were 80 years or older with those under 80, considering perioperative mortality and morbidity.
Methods. From January 1996 to December 1999, 794 patients underwent carotid endarterectomy for symptomatic or asymptomatic significant carotid lesions. Of these, 63 were aged 80 years or over. Preoperative examinations included carotid duplex-scan or duplex-scan and digital subtraction angiography and MR or CT cerebral scan. Under general anesthesia and continuous EEG perioperative monitoring, the plaque was excised and a Pruitt-Inahara shunt inserted routinely after plaque removal. Arteriotomy was closed using a PTFE or vein patch. Eversion endarterectomy and proximal re-anastomosis on the homolateral common carotid artery was performed in patients with significant kinking of the internal carotid artery. In a few cases, a vein or PTFE bypass to the distal internal carotid was performed. We analysed death and stroke rates from cerebrovascular incidents (relevant neurological complication rate: RNCR), TIA and RIND as well as non-neurological complications and death rate before the 30th postoperative day. Morbidity and mortality in the group aged 80 or over was compared to those in the group of under-80-year-olds. The χ2 test was used for the statistical analysis of risk factors, morbidity and mortality between the two groups (level of confidence p<0.05).
Results. The risk factors were similar in both groups, except for smoking which was significantly less frequent in octogenarians compared to younger patients (60.7 vs 36.5%, respectively, p<0.05). The female/male ratio was significantly higher in the octogenarian group (0.50 vs 0.29, p<0.05). The percentage of asymptomatic/symptomatic patients and the presentation of symptoms were similar in both groups. No statistical differences were observed in the stroke, TIA and mortality rate between the two groups.
Conclusions. The results of our study show that perioperative mortality and morbidity does not differ significantly in octogenarian patients compared to patients aged <80 undergoing carotid endarterectomy. However, it is worth making a few considerations. Only the fittest elderly patients are referred to the vascular surgeon who evaluates their surgical management. The clinical workup is performed more carefully in view of the fact that older patients tend to have significant concomitant morbidity. However, it has been postulated that surgery in the head and neck region poses less of a threat to elderly patients than surgery in other regions of the body. Prevention of stroke by carotid endarterectomy can greatly enhance the quality of life for the elderly population, provided that a careful preoperative evaluation is made and perioperative morbidity and mortality are comparable to those in the younger population.