Association of carotid revascularization approach with perioperative outcomes based on symptom status and degree of stenosis among octogenarians

Objective: Age ≥80 years is known to be an independent risk factor for periprocedural stroke after transfemoral carotid artery stenting (TF-CAS) but not after carotid endarterectomy (CEA). The objective of the present study was to compare the perioperative outcomes for CEA, TF-CAS, and transcarotid artery revascularization (TCAR) among octogenarian patients (aged ≥80 years) overall and stratified by symptom status and degree of stenosis. Methods: All patients aged ≥80 years with 50% to 99% carotid artery stenosis who had undergone CEA, TF-CAS, or TCAR in the Vascular Quality Initiative (2005-2020) were included. We compared the perioperative (30-day) incidence of ipsilateral stroke or death for CEA vs TF-CAS vs TCAR using analysis of variance and multivariable logistic regression models. The results were confirmed in a sensitivity analysis stratified by symptom status and degree of stenosis. Results: Overall, 28,571 carotid revascularization procedures were performed in patients aged ≥80 years: CEA, n = 20,912 (73.2%), TF-CAS, n = 3628 (12.7%), and TCAR, n = 4031 (14.1%). The median age was 83 years (interquartile range, 81.0-86.0 years); 49.8% of the patients were symptomatic (51.9% CEA, 46.2% TF-CAS, 42.4% TCAR); and 60.7% had high-grade stenosis (59.0% CEA, 65.2% TF-CAS, 65.4% TCAR). Perioperative stroke/death occurred most frequently following TF-CAS (6.6%), followed by TCAR (3.1%) and CEA (2.5%; P < .001). After adjusting for baseline differences between groups, the odds ratio (OR) for stroke/death was greater for TF-CAS vs CEA (adjusted OR [aOR], 3.35; 95% confidence interval [CI], 2.65-4.23), followed by TCAR vs CEA (aOR 1.49, 95% CI 1.18-1.87). The risk of perioperative stroke/death remained significantly greater for TF-CAS compared with CEA regardless of symptom status and degree of stenosis (P < .05 for all). In contrast, the risk of stroke/death was higher for TCAR vs CEA for asymptomatic patients (aOR, 2.04; 95% CI, 1.41-2.94) and those with high-grade stenosis (aOR, 1.49; 95% CI, 1.11-2.05) but similar for patients with symptomatic and moderate-grade disease (P > .05 for both). The risk of myocardial infarction was lower with TCAR (aOR, 0.59; 95% CI, 0.40-0.87) and TF-CAS (aOR, 0.56; 95% CI, 0.40-0.87) compared with CEA overall. Conclusions: Overall, TCAR and CEA can be safely offered to older adults, in particular, symptomatic patients and those with moderate-grade stenosis. TF-CAS should be avoided in older patients when possible.