The Impact of age and outcomes of high-risk patients on carotid revascularization

Joon-Kee Park; Shin-Young Woo; Yang-Jin Park; Dong-Ik Kim; Gyeong-Moon Kim; Woo-Keun Seo; Jong-Won Jung; Pyoung Jeon; Keon-Ha Kim; Young-Wook Kim; Shin-Seok Yang

doi:10.1177/17085381231155035

The Impact of age and outcomes of high-risk patients on carotid revascularization

Vascular. 2023 Feb 16:17085381231155035. doi: 10.1177/17085381231155035. Online ahead of print.

Authors

Affiliations

¹ Division of Vascular Surgery, Department of Surgery, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
² Department of Neurology, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
³ Department of Radiology, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
⁴ Division of Vascular Surgery, Department of Surgery, 58920Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

PMID: 36794829
DOI: 10.1177/17085381231155035

Abstract

Objectives: To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups.

Methods: We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs).

Results: A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group (n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922-10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391-11.155; p < 0.001) was also higher for CAS than CEA. In the age <75 subgroup of the Hr group (n = 428), CAS was associated with higher 30-day stroke/death (OR, 14.089; 95% CI, 1.314-151.036; p = 0.029). In the age ≥75 subgroup of the Hr (n = 139), there was no difference in 30-day stroke/death between CEA and CAS. In the age <75 subgroup of the Nr group (n = 1318), 30-day stroke/death (OR, 6.300; 95% CI, 2.797-14.193; p < 0.001) was higher in CAS. In the age ≥75 subgroup of the Nr group (n = 460), 30-day stroke/death (OR, 6.468; 95% CI, 1.862-22.471; p = 0.003) was higher in CAS.

Conclusions: In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.

Keywords: 30-day stroke and death; Carotid revascularization; carotid artery stenting; carotid endarterectomy; high-risk criteria for carotid endarterectomy.