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Surgical Intervention Among Asymptomatic Octogenarians with a Contralateral Occlusion Appears Selectively Warranted
Mark A. Eid
1, Jesse A. Columbo
1, Ian Perry
2, Dan Neal
2, Thomas S. Huber
2, Gilbert R. Upchurch, Jr.
2, Michol A. Cooper
2, David H. Stone
1, Salvatore T. Scali
2 1Dartmouth Hitchcock Medical Center, Lebanon, NH;
2University of Florida, Gainesville, FL
INTRODUCTION: The role of prophylactic carotid revascularization in asymptomatic octogenarians remains controversial. Current guidelines stipulate that asymptomatic older patients at “higher risk of stroke” on best medical therapy may still benefit from carotid intervention. Specifically, there is a widespread perception that a contralateral internal carotid artery (ICA) occlusion may confer an increased anatomic stroke risk, thus creating a surgical dilemma, particularly among older patients. The purpose of this analysis was to determine whether asymptomatic patients aged ≥80 derive a stroke or survival benefit from prophylactic carotid revascularization in the setting of a contralateral ICA occlusion.
METHODS: We analyzed asymptomatic patients with a contralateral occlusion who underwent carotid endarterectomy (CEA) or transcarotid artery revascularization (TCAR) using the Vascular Quality Initiative (VQI) database. Our primary exposure was age(<80 vs. ≥80 years). Primary outcomes included 30-day stroke, 30-day mortality, and 5-year survival. Logistic regression, Cox-regression, and propensity-score matching were used for risk adjustment.
RESULTS: We identified a total of 3,486 asymptomatic patients who underwent carotid surgery (CEA: 72.0%, TCAR: 28.0%) in the setting of a contralateral carotid occlusion; 15.0% were aged ≥80, 29.5% were female, and 91.1% were white. Older patients had more comorbidities and were more likely to undergo TCAR (<80-years: 26.7% vs. ≥80-years: 35.2%). The unadjusted 30-day stroke risk was similar between age groups (<80: 2.2%, vs. ≥80: 1.0%, p=0.26); however, mortality was 2-fold higher among octogenarians (<80: 0.9% vs. ≥80: 2.3%, p=0.04). The unadjusted risk of 30-day stroke or death was 2.9% for patients aged <80 and 4.0% for those ≥80 (p=0.34). Propensity score matching yielded 511 matched pairs. The composite endpoint of stroke or death in the matched cohort was 4.6% for patients <80 and 4.0% for those ≥80 (p=0.73). The 18-month stroke-free survival was 81.2%[95%CI 76-87%] in patients <80 and 78.0%[95%CI 73-84%] in those ≥80 years (log-rank p-value=0.4;
Figure). 5-year survival was similar between groups (<80: 84.6%[80.2-89.3%], ≥80: 80.8%[76.2-85.8%];log-rank p-value=0.4).
CONCLUSIONS: Perioperative outcomes in asymptomatic octogenarians with a contralateral ICA occlusion were similar to those in younger patients, validating the rationale to consider surgery in older patients at elevated stroke risk. Notably, both younger and older patients experienced composite perioperative stroke or death rates exceeding the current SVS safety benchmark of 3% in asymptomatic patients. Therefore, based on these results, carotid intervention should be selectively applied in octogenarians within this high-risk subgroup.
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