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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.

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