European Heart Journal Advance Access originally published online on July 10, 2007
European Heart Journal 2007 28(16):2044-2045; doi:10.1093/eurheartj/ehm251
Concerns on carotid stenting in octogenarians
Department of Neurology
Treviso General Hospital
Treviso
Italy
Vascular Surgery Section of the Geriatric Surgery Clinic
Department of Surgical and Gastroenterological Sciences
School of Medicine
University of Padua
Padua
Italy
Tel: +39 49 821 2239 Fax: +39 49 821 3184 E-mail address: enzo.ballotta{at}unipd.it
Zahn et al.1 should be complimented for creating an inter-hospital carotid artery stenting (CAS) registry and for presenting their 10 year experience, including many procedures performed on octogenarian. Although their analysis is retrospective in nature and unbalanced (321 patients > 80 years vs. 2557 patients < 80 years), it shows that in-hospital stroke or death rates increase significantly with older age, but the complication rate in octogenarians is not excessively high. The Zahn et al.'s article1 raises some concerns, however.
First, no distinction was drawn between ischemic and haemorrhagic strokes (as far as we know haemorrhagic stroke is not due to carotid disease) or between the various types of ischemic strokes (atheroembolic, cardioembolic, or lacunar infarction), so that patients with non-atheroembolic strokes should have been excluded from this analysis (it is worrying to see atrial fibrillation significantly more often in octogenarians than in the younger group!). The proportions of smokers and diabetic patients or patients with hyperlipidemia were lower among the octogenarians included in the study than among younger patients, so the former would be at lower risk of atherothrombotic stroke. So, how can the authors be sure that all 184 symptomatic octogenarians had symptoms related to the carotid stenosis?
Secondly, no mention was made of the timing of CAS vis-à-vis symptom onset, and "it is an incontestable fact that carotid endarterectomy (CEA) confers the maximum benefit provided it is undertaken as soon as possible after the onset of symptoms".2 We were among the first groups to demonstrate as much in a 4 year prospective study on 86 patients with minor stroke, 45 of them randomized to undergo early CEA while 41 had delayed CEA.3
Thirdly, since elderly patients were less likely to undergo CAS while on statin therapy, it would be interesting to know why the asymptomatic octogenarians underwent CAS, although some of them were on sub-optimal medical therapy.
Fourthly, since only in-hospital data were recorded, failure to report the event rate at 30 days prevents any comparison with other studies and casts a shadow of doubt over the study as a whole. The authors' conviction that "clinical events are extremely low after the first days of stent implantation" is debatable.1 CAS was aborted in 6.9% of octogenarians and there was a residual stenosis in 10%: whatever the reasons, these should be defined as cases of treatment failure and added to all the patients who had in-hospital events after CAS.
Finally, why should octogenarians be treated with CAS? It is particularly important to demonstrate that the interventional procedure adopted is safe, and therefore that the patient would be at a higher risk of stroke if said treatment is withheld, but the results of Zahn et al.1 analysis do not support this conclusion. A few years ago, in a study on octogenarians with contralateral carotid artery occlusion,4 we demonstrated that these patients can undergo CEA with no more risks or complications than younger patients with contralateral carotid occlusion, and we suggested that—until prospective, randomized trials to evaluate the role of CAS have been completed—CEA should remain the standard treatment for such patients.
References
- Zahn R, Ischinger T, Hochadel M, Zeymer U, Schmalz W, Treese N, Hauptmann KE, Seggewiß H, Janicke I, Haase H, Mudra H, Sengens J, for the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK). Carotid artery stenting in octogenarians: results from the ALKK Carotid Artery Stent (CAS) registry. Eur Heart J (2007) 28:370–375.
[Abstract/Free Full Text] - Naylor AR. First impressions are good, but appearances can be deceptive (editorial). Eur Heart J (2007) 28:276–277.
[Free Full Text] - Ballotta E, Da Giau G, Baracchini C, Abbruzzese E, Saladini M, Meneghetti G. Early versus delayed carotid endarterectomy after a non disabling ischemic stroke: a prospective randomized study. Surgery (2002) 131:287–293.[CrossRef][Web of Science][Medline]
- Ballotta E, Renon L, Da Giau G, Barbon B, Terranova O, Baracchini C. Octogenarians with contralateral carotid artery occlusion: a cohort at higher risk for carotid endarterectomy? J Vasc Surg (2004) 39:1003–1008.[CrossRef][Web of Science][Medline]
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