STOCKHOLM — Carotid artery stenting can be successfully and safely done in patients in their 80s, according to two reports at the annual congress of the European Society of Cardiology.
But the number of patients in each of the two studies was relatively small—33 patients in one study and 71 in the other—which means that the conclusions must be considered tentative. “I'm concerned about calculating event rates in fewer than 100 patients,” commented Antonio Columbo, M.D., director of the cardiac catheterization laboratory at EMO Centro Cuore Columbus in Milan. “There's no question that this is an encouraging experience, but older patients are at higher risk. We need a specific strategy for these patients.”
One study, conducted in Buenos Aires, compared the outcomes of carotid stenting in 33 patients aged at least 80 years with those of a concurrent group of 321 younger patients. The second was a registry analyzed in Milan with data on 71 octogenarians who had been treated at four centers in Italy and Germany.
The Argentine study included all patients who had carotid stenting done at Fundacion Favaloro from November 1995 through May 2004. The first patients treated in the series had their carotid stents placed without use of a distal protection device, which is now standard practice. The average age of the octogenarians was 82 years, compared with 66 years in the younger patients.
Angiographic success was achieved in 97% of the octogenarians, and clinical success was achieved in 94%, rates that were similar to those of the younger patients, reported Oscar Mendiz, M.D., chief of interventional cardiology at Fundacion Favaloro. During the first 30 days after treatment, the older patients had no major or minor strokes, one had a transient ischemic attack, and there were no treatment-related deaths but one nonrelated death. These rates were similar to those of the younger-patient group.
One-year follow-up was available for 32 of the older patients, and they had no additional strokes, deaths, or cases of carotid restenosis.
In the second report, the mean age of the 71 octogenarians was 83 years. Distal protection devices were used on all patients.
Carotid stenting was successful in all but one patient; two patients had nonocclusive dissections during the procedure, but these did not cause neurologic sequelae. During the first 30 days of follow-up, there was one major stroke, which led to the only death. Two patients had transient ischemic attacks, and one patient had a myocardial infarction, reported Ioannis Iakovou, M.D., a cardiologist at EMO Centro Cuore Columbus.
“Carotid stenting with cerebral protection in octogenarians appears to be feasible and safe, with a low rate of major complications,” said Dr. Iakovou.
One possible complication with right carotid stenting in very old patients is that the carotid sinus reflex can be triggered, causing a rapid drop in blood pressure, commented Giancarlo Biamino, M.D., director of interventional angiography at the Heart Center in Leipzig, Germany. As a result, “you must be ready to start an infusion of dopamine immediately in these patients,” he said. Because many older patients are on a β-blocker, treatment with atropine is not possible.
Another concern with this procedure in octogenarian patients is that their carotid arteries can be heavily calcified. To avoid causing a rupture, Dr. Biamino said he limits his dilating balloon to 4.5 mm, instead of the 6-mm balloon that is often used in younger patients.