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Objective: Asymptomatic carotid stenosis (ACS) can be successfully treated by carotid endarterectomy (CEA). However, patients ≥80 y/o are often considered high-risk due to their age and are offered non-surgical treatment options. The aim of this study was to evaluate whether age should be the primary exclusion factor for performing CEA in patients ≥80 y/o.
Methods: Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) from California and Florida were used to identify patients with ACS who underwent CEA from 2007 to 2011. ACS was defined as patients presenting with the ICD-9-CM code for ACS and no preoperative history of stroke, TIA, CVA, and neurologic deficits. Patients were divided into two cohorts: 65-79 y/o and ≥80 y/o. Demographics and baseline characteristics were examined using univariate analysis. Bivariate analysis was used to compare inpatient, 30 day, and 1 year outcomes. Uplift models were used to identify patient characteristics that predicted incremental harm of CEA on individual patients stratified by age.
Results: 39,039 patients were analyzed: 27,559 in the 65-79 y/o cohort, and 11,480 in the ≥80 y/o cohort. Inpatient mortality rates were low (>80: 0.43% vs 65-79: 0.27%; p=0.011) although significantly higher in the >80 group. Cumulative all-cause mortality rates rose in both groups and were significantly higher in the >80 group at 30 days (65-79: 0.46% vs ≥80: 0.78%; p<0.0001) and at 1 year (65-79: 1.90% vs ≥80: 3.07%; p<0.0001). Major complications (p=0.28) and stroke/TIA (p=0.84) were not significantly different between the two groups over 1 year. Uplift analysis demonstrated that preoperative anemia (OR=0.36, p<0.0001), diabetes (OR=0.08, p<0.0001), hypothyroidism (OR=0.30, p<0.0001), electrolyte disorders (OR=0.03, p<0.0001), and renal failure (OR=0.12, p<0.0001) all independently predict for increased risk of unsuccessful CEA regardless of age.
Conclusion: Age alone is not an effective assessment for successful CEAs in ACS patients. Uplift modeling demonstrates other characteristics and comorbidities predict unsuccessful CEAs despite a patient’s age. Age alone should not be a primary exclusion factor for deferral of CEA in patients with ACS.