Octogenarian Stroke Rate Lower With Carotid Endarterectomy vs. Stenting

NAPLES, FLA. – When it comes to cerebral revascularization of octogenarian patients, carotid endarterectomy may be the treatment of choice unless compelling evidence points to carotid artery angioplasty and stenting, according to Dr. Caron B. Rockman.

She and her colleagues compared in-hospital perioperative stroke and death rates between these procedures among older and younger patients in a study of 54,658 patients who underwent carotid revascularization in 2004 and 2005 in the Healthcare Cost and Utilization Project National Inpatient Sample database.

Octogenarians have been excluded from many previous trials of carotid endarterectomy (CEA), said Dr. Rockman, who is on the surgery faculty and is director of clinical research in the division of vascular surgery at New York University. However, patients aged 80 years and older accounted for 10,820 (or nearly 20%) of the patients.

"Advanced age is relevant when treatment of asymptomatic severe cerebrovascular disease is considered," Dr. Rockman said.

The prevalence of preoperative symptoms was essentially the same in the octogenarian (5.4%) and younger (5.2%) groups.

Dr. Rockman

"I am floored that 95% of octogenarians who get intervention are asymptomatic," said study discussant Dr. Samuel R. Money, chair of the department of surgery at the Mayo Clinic in Scottsdale, Ariz., at the meeting. Because the Nationwide Inpatient Sample data represent about 20% of U.S. hospital discharges, he estimated that approximately 50,000 people aged 80 years and older undergo these procedures each year in the United States. Dr. Money asked if such high utilization is justified in an era with medical management options such as statins. He estimated that these interventions cost $75 million to $1 billion annually.

"I agree with you," Dr. Rockman replied. "This is astounding."

She theorized that people who enter the ICD-9 procedural codes might incorrectly classify some patients as asymptomatic. "I hope people coding these are missing some of the symptomatology. It can be difficult to pick up [symptoms] from patient records, so I hope it’s not as alarming as it seems."

"However, I do think there is a role for endarterectomy or CAS in an elderly patient with severe disease," Dr. Rockman added.

The results of the study showed that "octogenarians had essentially equivalent rates of periprocedural stroke [1.1% in both groups], but slightly higher rates of in-hospital mortality than their younger counterparts," she said.

A meeting attendee asked why stroke outcomes were not significantly worse among octogenarians.

"I don’t know why I did not see it," said Dr. Rockman, noting that a separate meta-analysis of CAS studies found that the relative risk for periprocedural stroke in octogenarians fell above an acceptable rate of 3% in seven of eight studies (J. Am. Coll. Surg. 2009;208:1124-31). "It could be [because] this database is in-hospital only, so even if stroke occurs the day after discharge, it’s not included in this national database."

In a separate analysis of only octogenarian patients, the periprocedural stroke rate was significantly higher among those who underwent CAS than had CEA (2.2% vs. 1.1%). The rate also was consistently higher for both asymptomatic (1.9% vs. 0.9%) and symptomatic (5.2% vs. 2.3%) patients.

Because asymptomatic patients account for the largest proportion of the octogenarians, "this is arguably the most clinically important group," Dr. Rockman said.

Previous research has raised concerns about higher stroke risks associated with CAS vs. CEA in older patients (J. Vasc. Surg. 2004;40:1106-11; Catheter Cardiovasc. Interv. 2007;70:1025-33). Yet in the current study, a significantly greater percentage of asymptomatic octogenarians (10.1%) underwent CAS than did asymptomatic younger patients (5.7%).

Even though the in-hospital death rate was statistically significantly higher among octogenarians than among younger patients (1% vs. 0.6%), Dr. Rockman said that the small difference was, in her mind, "not clinically significant."

However, the story was different among symptomatic patients. The in-hospital death rate was 4.1% in the older group vs. 2.6% in younger patients. "I think this is concerning in both age categories," Dr. Rockman said. The investigators did not have access to cause-of-death information in the database.

Dr. Money asked about the causes of death in the study. "The cause of death is not in the database," Dr. Rockman responded, adding that only "in-hospital mortality" is noted.

"There are limits and good points about using a national database," Dr. Rockman said. She noted that procedures in the discharge administrative database "are really coded for the purpose of hospital reimbursement," but the large number of cases it contains may reflect "real world" practice better than do other types of studies.

Dr. Rockman said that she had no relevant disclosures.

NAPLES, FLA. – When it comes to cerebral revascularization of octogenarian patients, carotid endarterectomy may be the treatment of choice unless compelling evidence points to carotid artery angioplasty and stenting, according to Dr. Caron B. Rockman.

She and her colleagues compared in-hospital perioperative stroke and death rates between these procedures among older and younger patients in a study of 54,658 patients who underwent carotid revascularization in 2004 and 2005 in the Healthcare Cost and Utilization Project National Inpatient Sample database.

Octogenarians have been excluded from many previous trials of carotid endarterectomy (CEA), said Dr. Rockman, who is on the surgery faculty and is director of clinical research in the division of vascular surgery at New York University. However, patients aged 80 years and older accounted for 10,820 (or nearly 20%) of the patients.

"Advanced age is relevant when treatment of asymptomatic severe cerebrovascular disease is considered," Dr. Rockman said.

The prevalence of preoperative symptoms was essentially the same in the octogenarian (5.4%) and younger (5.2%) groups.

Dr. Rockman

"I am floored that 95% of octogenarians who get intervention are asymptomatic," said study discussant Dr. Samuel R. Money, chair of the department of surgery at the Mayo Clinic in Scottsdale, Ariz., at the meeting. Because the Nationwide Inpatient Sample data represent about 20% of U.S. hospital discharges, he estimated that approximately 50,000 people aged 80 years and older undergo these procedures each year in the United States. Dr. Money asked if such high utilization is justified in an era with medical management options such as statins. He estimated that these interventions cost $75 million to $1 billion annually.

"I agree with you," Dr. Rockman replied. "This is astounding."

She theorized that people who enter the ICD-9 procedural codes might incorrectly classify some patients as asymptomatic. "I hope people coding these are missing some of the symptomatology. It can be difficult to pick up [symptoms] from patient records, so I hope it’s not as alarming as it seems."

"However, I do think there is a role for endarterectomy or CAS in an elderly patient with severe disease," Dr. Rockman added.

The results of the study showed that "octogenarians had essentially equivalent rates of periprocedural stroke [1.1% in both groups], but slightly higher rates of in-hospital mortality than their younger counterparts," she said.

A meeting attendee asked why stroke outcomes were not significantly worse among octogenarians.

"I don’t know why I did not see it," said Dr. Rockman, noting that a separate meta-analysis of CAS studies found that the relative risk for periprocedural stroke in octogenarians fell above an acceptable rate of 3% in seven of eight studies (J. Am. Coll. Surg. 2009;208:1124-31). "It could be [because] this database is in-hospital only, so even if stroke occurs the day after discharge, it’s not included in this national database."

In a separate analysis of only octogenarian patients, the periprocedural stroke rate was significantly higher among those who underwent CAS than had CEA (2.2% vs. 1.1%). The rate also was consistently higher for both asymptomatic (1.9% vs. 0.9%) and symptomatic (5.2% vs. 2.3%) patients.

Because asymptomatic patients account for the largest proportion of the octogenarians, "this is arguably the most clinically important group," Dr. Rockman said.

Previous research has raised concerns about higher stroke risks associated with CAS vs. CEA in older patients (J. Vasc. Surg. 2004;40:1106-11; Catheter Cardiovasc. Interv. 2007;70:1025-33). Yet in the current study, a significantly greater percentage of asymptomatic octogenarians (10.1%) underwent CAS than did asymptomatic younger patients (5.7%).

Even though the in-hospital death rate was statistically significantly higher among octogenarians than among younger patients (1% vs. 0.6%), Dr. Rockman said that the small difference was, in her mind, "not clinically significant."

However, the story was different among symptomatic patients. The in-hospital death rate was 4.1% in the older group vs. 2.6% in younger patients. "I think this is concerning in both age categories," Dr. Rockman said. The investigators did not have access to cause-of-death information in the database.

Dr. Money asked about the causes of death in the study. "The cause of death is not in the database," Dr. Rockman responded, adding that only "in-hospital mortality" is noted.

"There are limits and good points about using a national database," Dr. Rockman said. She noted that procedures in the discharge administrative database "are really coded for the purpose of hospital reimbursement," but the large number of cases it contains may reflect "real world" practice better than do other types of studies.

Dr. Rockman said that she had no relevant disclosures.

NAPLES, FLA. – When it comes to cerebral revascularization of octogenarian patients, carotid endarterectomy may be the treatment of choice unless compelling evidence points to carotid artery angioplasty and stenting, according to Dr. Caron B. Rockman.

She and her colleagues compared in-hospital perioperative stroke and death rates between these procedures among older and younger patients in a study of 54,658 patients who underwent carotid revascularization in 2004 and 2005 in the Healthcare Cost and Utilization Project National Inpatient Sample database.

Octogenarians have been excluded from many previous trials of carotid endarterectomy (CEA), said Dr. Rockman, who is on the surgery faculty and is director of clinical research in the division of vascular surgery at New York University. However, patients aged 80 years and older accounted for 10,820 (or nearly 20%) of the patients.

"Advanced age is relevant when treatment of asymptomatic severe cerebrovascular disease is considered," Dr. Rockman said.

The prevalence of preoperative symptoms was essentially the same in the octogenarian (5.4%) and younger (5.2%) groups.

Dr. Rockman

"I am floored that 95% of octogenarians who get intervention are asymptomatic," said study discussant Dr. Samuel R. Money, chair of the department of surgery at the Mayo Clinic in Scottsdale, Ariz., at the meeting. Because the Nationwide Inpatient Sample data represent about 20% of U.S. hospital discharges, he estimated that approximately 50,000 people aged 80 years and older undergo these procedures each year in the United States. Dr. Money asked if such high utilization is justified in an era with medical management options such as statins. He estimated that these interventions cost $75 million to $1 billion annually.

"I agree with you," Dr. Rockman replied. "This is astounding."

She theorized that people who enter the ICD-9 procedural codes might incorrectly classify some patients as asymptomatic. "I hope people coding these are missing some of the symptomatology. It can be difficult to pick up [symptoms] from patient records, so I hope it’s not as alarming as it seems."

"However, I do think there is a role for endarterectomy or CAS in an elderly patient with severe disease," Dr. Rockman added.

The results of the study showed that "octogenarians had essentially equivalent rates of periprocedural stroke [1.1% in both groups], but slightly higher rates of in-hospital mortality than their younger counterparts," she said.

A meeting attendee asked why stroke outcomes were not significantly worse among octogenarians.

"I don’t know why I did not see it," said Dr. Rockman, noting that a separate meta-analysis of CAS studies found that the relative risk for periprocedural stroke in octogenarians fell above an acceptable rate of 3% in seven of eight studies (J. Am. Coll. Surg. 2009;208:1124-31). "It could be [because] this database is in-hospital only, so even if stroke occurs the day after discharge, it’s not included in this national database."

In a separate analysis of only octogenarian patients, the periprocedural stroke rate was significantly higher among those who underwent CAS than had CEA (2.2% vs. 1.1%). The rate also was consistently higher for both asymptomatic (1.9% vs. 0.9%) and symptomatic (5.2% vs. 2.3%) patients.

Because asymptomatic patients account for the largest proportion of the octogenarians, "this is arguably the most clinically important group," Dr. Rockman said.

Previous research has raised concerns about higher stroke risks associated with CAS vs. CEA in older patients (J. Vasc. Surg. 2004;40:1106-11; Catheter Cardiovasc. Interv. 2007;70:1025-33). Yet in the current study, a significantly greater percentage of asymptomatic octogenarians (10.1%) underwent CAS than did asymptomatic younger patients (5.7%).

Even though the in-hospital death rate was statistically significantly higher among octogenarians than among younger patients (1% vs. 0.6%), Dr. Rockman said that the small difference was, in her mind, "not clinically significant."

However, the story was different among symptomatic patients. The in-hospital death rate was 4.1% in the older group vs. 2.6% in younger patients. "I think this is concerning in both age categories," Dr. Rockman said. The investigators did not have access to cause-of-death information in the database.

Dr. Money asked about the causes of death in the study. "The cause of death is not in the database," Dr. Rockman responded, adding that only "in-hospital mortality" is noted.

"There are limits and good points about using a national database," Dr. Rockman said. She noted that procedures in the discharge administrative database "are really coded for the purpose of hospital reimbursement," but the large number of cases it contains may reflect "real world" practice better than do other types of studies.

Dr. Rockman said that she had no relevant disclosures.