Search

ObjectiveCarotid endarterectomy (CEA) is proven to be the most effective treatment for symptomatic carotid artery stenosis of 50% or greater and asymptomatic carotid stenosis of 60% or greater. Although the prevalence of carotid artery disease increases with age, most prospective and randomized trials have excluded patients older than 80 years, implying that they are either at higher procedural risk or have decreased life expectancy. Since advanced age (≥80 years) has been viewed as a “high-risk” indicator for CEA, age ≥80 years has been used as an indication for alternative treatment. The study was conducted to determine if age ≥80 years is related to increased morbidity, mortality, and length of stay in patients undergoing CEA.MethodsIn the 12-year period from 1993 to 2004, 2217 CEAs were performed in 1961 patients. Three hundred sixty procedures were performed in 334 patients ≥80 years. Demographics, presentation, risk factors, operative outcome, and survival were analyzed. Contemporary literature was reviewed and the results summarized.ResultsIn patients aged ≥80 years, compared with their younger cohort, there was no difference in stroke (1.1% vs 0.8%, P = .333) but there was a higher operative mortality (1.9% vs 0.8%, P = .053). The combined stroke/death rate was higher in octogenarians (3.1% vs 1.5%, P = .041). This difference was due to the greater stroke/death rate in symptomatic octogenarians vs asymptomatic octogenarians (6.0% vs 0.9%, P = .007). The average postoperative length of stay was 3.2 ± 4.8 days for octogenarians compared with 2.4 ± 3.5 days for their younger counterparts (P < .001). Thirty-seven percent of the octogenarians were discharged on the first postoperative day vs 51% (P < .001), whereas 13% remained hospitalized beyond 5 days vs 8% (P = .003). Although Kaplan-Meier survival curves show a higher mortality in octogenarians, survival after CEA approaches that of the overall population. A summary of the contemporary literature of CEA in 2204 patients ≥80 shows an operative stroke rate of 2.23% and death rate of 1.28%, with a combined stroke/death rate of 3.51%.ConclusionCEA is a safe and effective procedure in the octogenarian. The combined stroke/death rate is increased in patients aged ≥80, indicating increased risk, predominantly in symptomatic patients. Although CEA risk in octogenarians is higher compared with a younger cohort, outcomes remain within acceptable national guidelines and within outcome measures known to confer benefit compared with best medical care. Therefore, the term “high risk” should not be arbitrarily applied to patients reaching the 80-year threshold. This is confirmed by the contemporary literature.

Objective As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scaning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. Methods One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the χ 2 test and Fisher exact test. Results We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre–radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. Conclusions Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation–treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.