Is age of 80 years a threshold for carotid revascularization?
ABSTRACT Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.
Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.
After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 - 8.8%) following CEA. A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 - 8.8%)
MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.
Is Age of 80 Years a Threshold for Carotid Revascularization?
Current Cardiology Reviews, 2011, 7, 15-2115
1573-403X/11 $58.00+.00 © 2011 Bentham Science Publishers Ltd.
Boudewijn L. Reichmann, Guus W. van Lammeren, Frans L. Moll and Gert J. de Borst*
Department of Vascular Surgery, University Medical Centre Utrecht; The Netherlands
Abstract: Background and purpose: Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid
Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often
confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to
CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of
carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years
should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available litera-
Methods: Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to
identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on
either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate
(disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.
Results: After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA.
A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9%
(range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.
A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octoge-
narians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were in-
cluded the MAE following CEA is 2.4% (range 0 – 8.8%)
Conclusions: MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger
patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute
cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the
treatment of significant carotid artery stenoses, even in the very elderly.
Keywords: Carotid revascularization, angioplasty, stenting, octogenarians, demographic features, revascularization.
Carotid Angioplasty and Stenting (CAS) has emerged as
an alternative to Carotid Endarterectomy (CEA) for the
treatment of carotid artery stenoses in the prevention of
stroke 1. Recent results of large randomized trials have
shown that CAS however has a higher peri-procedural com-
plication rate compared to CEA [2-4]. The authors concluded
that CAS should only be considered in high-risk patients not
suitable for surgery and that CEA remains the gold standard
until long-term results of randomized trials can be reported.
The question remains which patients should be consid-
ered as high-risk patients. Previous neck surgery, prior neck
cancer with radiation therapy, clinical significant cardiopul-
monary disease or an age above 80 have been exclusion
criteria in many large carotid trials that were conducted to
evaluate the durability of CEA for the prevention of stroke
[5-9]. Age has also been identified as an independent predic-
tor of complications in carotid interventions [10-12]. Mean
life expectancy has steadily increased over time, and elderly
*Address correspondence to this author at the University Medical Center
Utrecht, Department of Vascular Surgery, G 04.129 PO Box 85500 3508
GA Utrecht, The Netherlands; Tel: 0031-88-7556965;
Fax: 0031-88-7551944; E-mail: G.J.deBorstfirstname.lastname@example.org
people have become the fastest growing population segment
in industrialized countries. Hence, elderly people are typi-
cally seen in everyday clinical practice and will become an
increasingly important group of patients in the future. “High-
risk” patients were often offered the endovascular alternative
to surgical treatment because CAS is considered to be a less
invasive revascularization option. Some authors state that
CAS can be performed safely in high-risk patients [13-15],
but subgroups often are too small to draw any conclusions on
the procedural risk of for example patients of higher age.
Octogenarians however, were excluded from most trials
evaluating CAS. To date, there has not been a randomized
trial comparing CAS with CEA in octogenarians.
In order to answer two specific questions; 1) is carotid
revascularization in octogenarians safe to perform; and 2) is
CAS compared to CEA a safer treatment option for octoge-
narians in terms of perioperative MAE; we systematically
reviewed current literature on carotid revascularization in
Literature was searched to identify all relevant studies on
carotid revascularization in octogenarians. The search was
restricted to papers published between January 2000 and
Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
June 2010. Studies were initially identified from the Med-
line/Pubmed database, EMBASE and the Cochrane database
using the search terms “carotid stenosis”, “carotid an-
gioplasty”, “carotid stenting”, “carotid revascularization”,
“carotid endarterectomy”, “octogenarians” and “(very) eld-
Studies were included if they reported on octogenarians
treated by CAS or CEA. Results of major adverse events
(MAE) (disabling stroke, myocardial infarction or death) had
to be described in order to be included. Studies however
were excluded if: 1) The age of the patient population was
<80 years, 2) review articles or letters did not describe rates
of major adverse events, 3) articles were written in non-
English language . The reference list of the included articles
was also screened for additional studies concerning our sub-
ject. Data on 30-day MAE rates as well demographic fea-
tures of the included patients were extracted from the articles
Sixty-nine studies were initially identified with our
search strategy (Fig. 1; flow chart). Of these 69 initial arti-
cles, 10 articles did not meet our inclusion criteria, 2 were
case reports, 4 articles were written in non-English languages
and 4 articles lacked description of Major Adverse Event
(MAE). Six articles were excluded because there was a lack
of demographic data on included patients and 7 articles de-
scribed carotid revascularization in a patient population with
an average age <80 years. After exclusion 46 articles met our
inclusion criteria (18 CAS and 28 CEA) [16-60].
Carotid Angioplasty and Stenting in Octogenarians
The combined amount of CAS procedures performed in
the included articles was 10.896. Of these procedures 2.837
were performed in octogenarians. Demographic features and
an outline of included articles are shown in Table 1. Forty-
nine percent of patients treated by CAS were symptomatic.
In two series, a significant higher complication rate was
observed in symptomatic octogenarians compared to asymp-
tomatic octogenarians [21, 24].
Other series included in this review did not analyze the
difference between symptomatic and asymptomatic octoge-
narians. An Embolic Protection Device (EPD) was used in
86% of the patients. Usman et al who conducted a meta-
analysis on carotid revascularization in octogenarians de-
scribe a review of 826 patients 19. They concluded that octo-
genarians undergoing CAS have a 3.46-times higher absolute
risk of stroke than those undergoing CEA, with no signifi-
cant difference in mortality and a trend toward a lower rate
of myocardial infarction. The rate of MAE (disabling stroke,
myocardial infarction or death) varied from 1,6 to 24%. The
total number of MAE was 206 which corresponds to a com-
bined MAE rate of 6,9% in the 2.837 included patients.
These MAE’s were mainly stroke related; myocardial infarc-
tion was relatively rare following CAS. Zahn et al reported
only non-fatal strokes and death and did not analyze cardiac
24. Their MAE rate of 5,5% is therefore
Fig. (1). Flow chart of search results.
Is Age of 80 Years a Threshold for Carotid Revascularization? Current Cardiology Reviews, 2011, Vol. 7, No. 1 17
peri-procedural MAE [25, 27, 31], and thus age over 80 was
an exclusion criterium in many carotid trials. This policy
however was not endorsed by the results of other authors in
this review. They did not observe significant increases in
complication rates of octogenarians compared to younger
The use of an EPD is essential in the prevention of peri-
procedural cerebrovascular events according to three authors,
because of the observed higher event rate compared to un-
protected CAS procedures [23, 24, 26].
An age > 80 years is as an independent risk factor for
Carotid Endarterectomy in Octogenarians
Much more data are available on CEA in octogenarians.
The included articles and their demographic features are
outlined in Table 2. The by far largest cohort was reported
by Lichtman et al. who analyzed data of all 140.376 patients
older than 80 years undergoing CEA in the United States
during a period of 6 years (1993-1999) . They collected
data on patients from their medical records. Their group
reported a 30-day mortality rate of 2,2% but did not specify
the cause of death nor did they report on cerebrovascular
complication rates. Ninety-three of the total included patients
in this review are coming from their patient population. If
this group is included the combined MAE rate would be
2,4%. This however considerably underestimates the exact
MAE rates because of the lack of figures about neurological
and cardiac complications.
When the study of Lichtman is not included, a patient
population of 60.060 containing 14.365 octogenarians re-
mains for analysis. In total 47% of the included patients
undergoing CEA were symptomatic. The MAE rates in the
included articles varied between 0-8,3%. The total number of
MAE was 606 on a total of 14.365 CEA’s in patients older
than 80. The combined MAE rate was 4.2%. Two authors
describe that especially symptomatic octogenarians are more
at risk for peri-procedural complications compared to asymp-
tomatic patients undergoing CEA [39, 59].
With the increasing life expectancy clinicians are more
often confronted with elderly patients affected by carotid
obstructive disease. It has been estimated that 30-40% of
strokes in octogenarians are secondary to stenotic or occlu-
sive disease of the carotid bifurcation . Carotid revascu-
larization in the elderly remains controversial and conflicting
Table 1. Carotid Angioplasty and Stenting (CAS) Study Collection and 30-day MAE Rates.
First author YearTotal CAS Octogenarians, N MaleMean ageSymptomaticEPD usedNr of MAE'sMAE (%)
Micari  2010 198 198 68% 83.2 39% 100% 5 2.5%
Grant  2010 418 418 63% 83.2 32% 79% 14 3.3%
Bacharach  2010 235 78 72% 83.5 20% 99% 7 9.0%
Usman*  2009 826 826 NR 82.2 65% 100% 84 9.9%
Linfante  2009 178 24 67% 82.4 71% 100% 2 8.4%
Cremonesi  2009 1.523 237 72% NR 24% 88% 5 2.1%
Jackson  2008 215 35 53% NR 41% 92% 4 11.4%
Henry  2008 930 121 72% 82.0 64% 95% 2 1.6%
Velez  2008 816 126 56% 82.9 40% 50% 3 2.7%
Zahn**  2007 2.878 321 65% 82.5 61% 68% 18 5.5%
Lam  2007 135 37 65% 85.0 100% 99% 4 10.8%
Villalobos  2006 75 75 55% 83.1 56% 54% 18 24.0%
Stanziale  2006 382 87 83% 83.0 18% 62% 8 9.2%
Setacci  2006 1.222 144 75% 82.0 65% 92% 5 3.5%
Longo  2005 158 29 74% 82.3 17% 89% 1 3.4%
Hobson  2004 749 99 64% NR 30% 100% 12 12.1%
Roubin  2001 604 66 67% NR 52% 100% 11 16.0%
Shawl  2000 170 42 59% NR 61% 0% 1 2.9%
Total 11.712 2.963 67% 82.9 49% 86% 203 6.9%
* Meta-analysis of CAS vs. CEA in octogenarians
** All non-fatal strokes and death
MAE: Major Adverse Events (disabling stroke, myocardial infarction or death)
18 Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
results on peri-procedural outcome have been reported. Two
studies however, have shown that, on average, 80% of octo-
genarians survive at least 4 years after endarterectomy and
that the vast majority is stroke free at 5 to 10 years follow-up
[58, 62]. Norman et al conclude that the likelihood of living
long enough to gain benefit from a carotid endarterectomy is
not jeopardized by being too old . Elderly patients with a
symptomatic carotid stenosis treated by best medical treat-
ment have the highest risk on future cerebrovascular events
. It might therefore be beneficial to offer any carotid
revascularization, whether surgical or endovascular, to octo-
genarians to decrease this relatively high risk of (recurrent)
Table 2. Carotid Endarterectomy (CEA) Study Collection and 30-day MAE Rates.
First author Year Total CEA Octogenarians, N Male Mean age, y SymptomaticNr of MAE's MAE (%)
Lichtman  2010 140.376 140.376 NR 83.0 NR 3.088 2.2%
Usman*  2009 7.017 7.017 NR 82.7 54% 316 4.5%
Halm  2009 9.308 2.198 NR NR NR 106 4.8%
Bremner  2008 195 105 62% 83.7 43% 6 5.7%
Ballotta  2006 1.260 112 62% 84.2 66% 1 0.9%
Teso  2005 14.679 2.379 54% NR 11% 100 4.2%
Pulli  2005 1.883 149 70% NR NR 1 0.6%
Miller  2005 2.217 360 NR 83.6 59% 15 4.2%
Lau  2005 286 33 100% 82.0 51% 3 8.0%
Grego  2005 1.733 125 66% NR 50% 1 0.8%
Durward  2005 1.800 26 NR 91.3 81% 0 0.0%
Varghese  2004 359 33 61% NR 76% 3 8.8%
Hingorani  2004 565 299 51% NR 43% 8 2.7%
Ballotta  2004 1.150 92 52% 83.7 66% 0 0.0%
Witz  2003 360 47 66% 82.0 51% 4 8.3%
Rockman  2003 698 161 52% NR 46% 4 2.5%
Pruner  2003 3.430 269 62% 82.9 83% 8 3.1%
Norman  2003 2.023 151 67% NR NR 4 2.6%
Salameh  2002 293 42 NR NR NR 2 4.8%
Ozsvath  2002 3.932 125 45% 83.0 50% 3 2.4%
Metz  2002 32 32 50% 82.0 100% 1 3.2%
Cartier  2002 475 65 51% 82.6 76% 2 2.8%
Saha  2002 101 101 NR 86.5 71% 3 3.0%
Ommer  2001 2.262 70 63% 82.9 74% 3 4.2%
Lepore  2001 366 42 63% 82.8 40% 1 2.4%
Ting  2000 656 57 58% 82.0 86% 4 6.8%
Schneider  2000 582 88 61% 83.2 75% 1 1.1%
Maxwell  2000 2.398 187 47% 83.0 65% 8 4.1%
Total incl. Lichtman et al 200.436 154.741 NR 83.5 47% 3.695 2.4%
Total excl. Lichtman et al 60.060 14.365 NR 83.5 NR 606 4.2%
* 30-day Mortality rates, stroke not analysed
** Meta-analysis of CAS vs. CEA in octogenarians
MAE: Major Adverse Events (disabling stroke, myocardial infarction or death)
Is Age of 80 Years a Threshold for Carotid Revascularization? Current Cardiology Reviews, 2011, Vol. 7, No. 1 19
narians have an increased risk of major adverse events dur-
ing CAS compared to CEA. A recent meta-analysis concern-
ing carotid revascularization in octogenarians showed that
the peri-procedural all-stroke rate was significantly higher
during CAS . The absolute risk on stroke was 3.46-times
higher compared to patients undergoing CEA. There was
also a trend towards higher mortality and myocardial infarc-
tion rates but these results did not reach statistical signifi-
cance. Several other authors like the CREST investigators
endorse the conclusion of this meta-analysis. After interim
analysis of the results of the lead-in phase of the CREST trial
the inclusion of octogenarians was stopped. Octogenarians
showed a 30-day stroke/death rate of 12.1% compared to
3.2% in younger patients .
Other authors invalidate inferiority of CAS in octoge-
narians and showed excellent results in their patient popula-
tions [16, 18, 20, 28]. A recent meta-analysis by Bonati et al.
containing the pooled data of three recent large randomized
trials confirmed the significant higher complication rates
following CAS in patients > 75 years 
The explanation for this increase in major adverse events
after CAS compared to CEA is poorly defined. Anatomic
characteristics might play an important role in the occurrence
of major adverse events. Octogenarians have an increased
incidence of complex anatomic risk factors compared to
younger patients [25, 65]. Lam et al have described several
of these characteristics. They concluded that octogenarians
have an increased incidence of unfavorable arch elongation,
arch calcification, common carotid or innominate artery
origin stenosis, common carotid artery tortuosity, and inter-
nal carotid artery tortuosity. Increased arch calcium content
and type II aortic arches may be markers of increased poten-
tial for embolization during endovascular manipulation that
transverses the aortic arch . The rate of embolic events
during CAS is considered to decrease when an embolic pro-
tection device (EPD) is used but preliminary manipulation of
interventional devices through a calcified aortic arch might
already have contributed to cerebral lesions, prior to EPD
placement. The discussion on the standard use of CPD not
closed; also in the light of recent findings that new cerebral
infarctions were higher in CAS than in CEA, especially in
CPD assisted CAS . Kastrup et al also described the
correlation between the incidence of new lesions on diffu-
sion–weighted imaging and aortic arch calcification in the
Another explanation might be found in plaque character-
istics at the target site. There are no data available in the
current literature reporting on specific carotid plaque charac-
teristics in octogenarians, but plaque stability has been re-
ported to decrease with age . It might be conceivable that
the underlying plaque composition in octogenarians is more
unstable and rupture prone, compared to carotid plaques in
younger patients, which might contribute to the increased
risk for thrombo-embolic events during CAS, due to plaque
disruption initiated by endovascular devices and stents. Our
study group is currently conducting a study concerning
plaque stability in octogenarians compared to younger pa-
tients, but results have to be awaited.
The result of this systematic review shows that octoge-
EPD might prevent some events but the embolization can
occur during each step of the procedure. A lot of these mi-
cro-emboli occur subclinically but some factors could pro-
voke subclinical events and lesions to become clinical. One
of these factors is cerebral reserve but data concerning the
effect of cerebral reserve on outcome of carotid revasculari-
zation is poorly defined in octogenarians. Chaer et al studied
cerebral reserve and saw that an age >/=70 is associated with
poor cerebral reserve in patients with significant carotid
stenosis as measured by Cerebral Blood Flow response to an
acetazolamide challenge . This poor reserve might make
older patients more sensitive to micro-emboli and therefore
explain the higher risk of stroke during CAS compared to
Interventionalists often attribute higher rates of major
adverse events during CAS in large randomized trials to the
fact that less experienced interventionalists are compared to
experienced surgeons. Experienced interventionalists are
more likely to recognize treacherous anatomy and make
adjustments to minimize procedural risks than less experi-
enced operators. Patient selection and a well considered
choice for an either surgical or endovascular approach re-
mains a key factor in carotid revascularization. Some authors
therefore believe that when appropriate patient selection and
evaluation of their preoperative risk factors is performed
equal peri-procedural results can be achieved in CAS and
CEA in high risk patients 71 So far, however, the data derived
in this review concluded otherwise.
Whether or not a patient is symptomatic could attribute to
the risk of major adverse events. A carotid artery stent regis-
try noted a significant difference in stroke rates in sympto-
matic octogenarians of 7.1% versus 3.9% in younger symp-
tomatic patients. This relevant difference was not found in
asymptomatic patients (3.4% vs. 2.6%). Other authors, in-
cluding the CREST investigators, did not find an increased
peri-procedural complication rate between symptomatic and
asymptomatic octogenarians 
The data obtained in this review show a 30-day MAE rate
of 4.2% following CEA in octogenarians. This MAE rates
are consistent with complication rates of recent large ran-
domized trials in non-octogenarians [2-4]. It seems a consis-
tent finding that CEA can be safely performed in the very
elderly with equal complication rates compared to a younger
This review is limited by the age cut-off point. On pur-
pose, we focused on octogenarians (age > 80 years) whereas
some authors use an age > 75 years to define elderly in their
studies. Our main focus was on octogenarians and therefore
we had to discard and exclude 7 articles from our review.
Embolization is not uncommon during CAS. The use of
Age is not a criterion to withhold patients from surgery.
CEA in both symptomatic and asymptomatic octogenarians
can be performed with comparable and acceptable peri-
procedural complication rates as in younger patients. Higher
complication rates in patients older than 80 years occur with
CAS. Therefore, CEA must remain the gold standard in the
20 Current Cardiology Reviews, 2011, Vol. 7, No. 1 Reichmann et al.
treatment of carotid occlusive disease, also in patients above
the age of 80.
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Received: October 16, 2010 Revised: October 16, 2010 Accepted: January 7, 2011