title: Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly.
abstract: BACKGROUND
  The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone.
  
  
  METHODS
  From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period.
  
  
  RESULTS
  There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65).
  
  
  CONCLUSIONS
  CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy. Electronic address: enzo.ballotta@unipd.it.
authors.forename: Enzo
authors.initials: E
authors.lastname: Ballotta
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Toniato
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Da Roit
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Renata
authors.initials: R
authors.lastname: Lorenzetti
authors.affiliation: Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Piatto
authors.affiliation: Department of Neurosciences, University of Padua, School of Medicine, Padova, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Baracchini
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases; D002317:Cardiovascular Agents / Q000627:therapeutic use; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D003952:Diagnostic Imaging / Q000379:methods; D018450:Disease Progression; D018572:Disease-Free Survival; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D018579:Patient Selection; D012008:Recurrence; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents