Carotid endarterectomy in octogenarians: Comparison with patient characteristics and outcomes in younger patients

Objectives: Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have su ggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We com pared patients and results for caroti d endarterectomy in octogenarians and younger patients. Methods: We reviewed the results for 582 primary carotid endarterectomies ( 90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected pro spectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, an d selective patching. Main outcome measures were perioperative and late ips ilateral stroke and death. Results: The two groups were similar with respect to indications for caroti d endarterectomy and patient characteristics, except that octogenarians wer e more Likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Caro tid endarterectomy was performed for asymptomatic disease in 27% of the oct ogenarians and 33% of the younger patients (P = .31). Stenosis was greater than or equal to 80% in 90% of the octogenarians and 78% of the younger pat ients (P = .014). Perioperative strokes, all of which were ipsilateral, occ urred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00 ). No octogenarians and two younger patients died within 30 days of surgery (P = 1.00). Length of stay and direct costs associated with carotid endart erectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients ( two ipsilateral). Life table estimates of freedom from ipsilateral stroke a t 2 years were 98% and 97% for octogenarians and younger patients, respecti vely (log-rank P = .69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively (P = .11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period. Conclusions: Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, com plications, and resource utilization were similar for the two groups, and m ore than 75% of octogenarians survived 4 years after undergoing carotid end arterectomy. Cost-benefit analyses for carotid endarterectomy, which are hi ghly sensitive to expected patient survival, might not be pertinent to indi vidual patient situations. Intellectually intact octogenarians without unus ually severe comorbidities are good candidates for and should be offered th e benefits of carotid endarterectomy.