Carotid artery stenting in nonagenarians: Are there benefits in surgically treating this high risk population?

Background: Carotid angioplasty and stenting (CAS) is considered desirable treatment for patients at high risk for carotid endarterectomy. Despite a growing elderly population, scant data exist on CAS in nonagenarians. Nonagenarians represent a high risk population for open and endovascular interventions due to unique anatomic and physiologic characteristics presenting significant challenges to anesthesiologists and surgeons. Studies have quantified that symptomatic and asymptomatic patients should survive 2 and 5 years, respectively, to gain benefit from revascularization; thus doubt exists on the value of CAS in nonagenarian patients because of their extreme age and unique risk factors. We therefore evaluated CAS safety and efficacy in our hospital's nonagenarian population. Methods: CAS cases performed in patients aged ≥90 years between April 2005 and January 2013 were retrospectively examined. Relevant demographic and medical data were reviewed. Rates of perioperative complications and complications until end of follow-up (including stroke, myocardial infarction, death) were compiled. Results: Among 21 nonagenarian cases of stent placement performed in 20 patients (11 symptomatic, nine asymptomatic), two patients suffered perioperative stroke after undergoing CAS and one died during the perioperative period. 50% of symptomatic patients were alive at 19 months; 50% of asymptomatic patients were alive at 47 months. Conclusions: CAS in nonagenarian patients carried increased risk of perioperative ischemic events, compared with contemporary trial results in symptomatic and asymptomatic patients. Further, mean survival time postprocedure fell short of guidelines for receiving procedural benefit. Although larger scale multicenter research is needed, we recommend careful consideration of overall health status when contemplating stenting in nonagenarians.