Age and Ageing Advance Access originally published online on November 17, 2006
Age and Ageing 2007 36(1):102-104; doi:10.1093/ageing/afl119
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Case Reports |
Endovascular intervention for symptomatic bilateral carotid artery stenosis in an octogenarian
Department of Clinical Neurosciences, Atkinson Morley Wing, St George's Hospital, Blackshaw Road, London SW17 0QT, UK
Address correspondence to: G. C. Cloud. Tel: (+44) 208 725 2470. Fax: (+44) 208 725 3291. Email: g.cloud{at}sgul.ac.uk
Abstract
An 89-year-old man presented with two separate minor stroke episodes due to high grade bilateral carotid stenoses, which were successfully treated with endovascular angioplasty and stenting. The role of operative interventions for high grade symptomatic carotid stenosis in patients aged over 80 years is discussed.
Keywords: stroke, carotid artery stenosis, carotid stenting, elderly
An 89-year-old, right-handed man presented with sudden onset of left arm weakness and numbness.
His known risk factors for cerebrovascular disease were treated: hypertension, coronary artery disease, hypercholesterolaemia and previous smoking history of 20 pack-years. On examination, he had mild pyramidal weakness and diminished sensation in his left arm.
Computerised tomography (CT) of his brain was normal. However, magnetic resonance imaging (MRI) of his brain demonstrated an acute infarct in the right corona radiata (Appendix 1 Available online at http://ageing.oxfordjournals.org). He was in sinus rhythm and transthoracic echocardiography was normal. Carotid Doppler demonstrated bilateral proximal stenosis of the internal carotid arteries (ICA) of more than 90% by velocities. Magnetic resonance angiography (MRA) confirmed this (Appendix 2 Available online at http://ageing.oxfordjournals.org). Significant functional recovery of the arm was observed within a week of admission.
After informed consent, he was randomly entered into the International Carotid Stenting Study (ICSS) [1] for treatment of his symptomatic extracranial internal carotid artery stenosis. He was allocated to the CAS (carotid artery stenting) arm of the trial, the other being CEA (carotid endarterectomy). One month later, he underwent successful, uncomplicated right ICA angioplasty and stenting with aspirin and clopidogrel antiplatelet cover.
At the 1-month review, there were no recurrent symptoms of right ICA territory cerebral ischaemia. There was no evidence of re-stenosis or impaired flow through lumen of the stent on ultrasound of the right ICA, while the left ICA stenosis remained unchanged.
Two months later, he presented with an episode of weakness and numbness of the right arm and mild dysphasia. Repeat MRI of his brain showed an acute left frontal sub-cortical infarct and persistent left proximal severe ICA stenosis, narrower than on the previous MRA.
Again the patient recovered well. Treatment options (medical, CAS or CEA) concerning his now symptomatic left ICA stenosis were discussed with the patient. The patient elected for CAS, based on his recent experience (he could not be randomised again into ICSS). One month later, he underwent uncomplicated angioplasty and stenting of his left ICA stenosis (Figure 1).
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At the 2-year follow-up, the patient remained asymptomatic. Ultrasound of the carotid arteries showed patent stents with no evidence of re-stenosis.
Stroke is a major cause of preventable disability in an ageing population. Carotid stenosis is an important cause of stroke. CEA is an effective treatment for symptomatic carotid artery stenosis of 70–99%, with up to 20% absolute risk reduction of stroke at 2 years compared with optimal medical care [2]. This is in contrast to asymptomatic carotid artery stenosis for which there is no seeming value in surgical intervention for patients aged over 75 years [3]. Most prospective and randomised trials have excluded patients older than 80 years. The risks of CEA in patients over the age of 75 years are thought to be related more to existing co-morbidities than to age itself, and several population/single centre studies have shown the value of CEA in those aged over 80 years [4, 5]. CAS is a promising new treatment for carotid stenosis [6] and has recently been shown to have similar results to that of CEA over short term follow-up [7]; however, there is some concern that CAS in octogenarians may be associated with adverse risk [8]. Another study has suggested that for patients in whom CEA is associated with an increased adverse risk, such as greatly increased age, CAS with the use of an emboli-protection device is comparable to CEA in the prevention of stroke and primary end points [9].
This case illustrates that carotid stenosis is a treatable condition in symptomatic patients of great age, and that age should not be a deterrent for appropriate investigation of patients presenting with carotid territory stroke symptoms. However, the safety, effectiveness and role of CAS in different patient groups, including the very elderly, requires clarification. Until then, patients, such as the case discussed here, are best treated by CEA or in randomised studies such as ICSS [10].
- Carotid stenosis is an important treatable cause of stroke.
- Symptomatic patients aged over 80 should be investigated and considered for operative intervention.
- Endovascular angioplasty and stenting is a new promising treatment and a possible alternative to carotid endarterectomy.
The ICSS has been funded by research grants from the Stroke Association, Sanofi-Synthélabo and the European Union.
None declared.
The patient discussed in this report has given written consent for using details of his treatment for purposes of medical education, including publication in a scientific journal.
References
- ICSS (International Carotid Stenting Study CAVATAS-2). http://www.ion.ucl.ac.uk/cavatas_icss/index2.htm.
- North American Symptomatic Carotid Endarterectomy Trial Collaborators. (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade stenosis. N Engl J Med 325 445–53.[Abstract]
- Halliday A, Mansfield A, Marro J, et al. (2004) MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363 1491–502.[CrossRef][Web of Science][Medline]
- Norman PE, Semmens JB, Laurvick CL, Lawrence-Brown M. (2003) Long—term relative survival in elderly patients after carotid endarterectomy. A population-based study. Stroke 34 95–8.
- Miller MT, Comerota AJ, Tzillinis A, Daoud Y, Hammerling J. (2005) Carotid endarterectomy in octogenarians: does increased age indicate "high risk?". J Vasc Surg 41 231–37.[CrossRef][Web of Science][Medline]
- Wholey MH, Wholey M, Mathias K, et al. (2000) Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv 50 160–67.[CrossRef][Web of Science][Medline]
- CAVATAS investigators. (2001) Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 357 1729–37.[CrossRef][Web of Science][Medline]
- Hobson RW, Howard VJ, Roubin GS, et al. (2004) CREST investigators. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rate in the Carotid Revascularization Endarterectomy Versus Stenting Trial lead in phase. J Vasc Surg 40(6) 1106–11.[CrossRef][Web of Science][Medline]
- Yadav JS, Wholey MH, Kuntz RE, et al. (2004) Protected carotid-artery stenting versus endarterectomy in high risk patients. N Engl J Med 351 1493–501.
[Abstract/Free Full Text] - Coward LJ, Featherstone RL, Brown MM. (2005) Safety and efficacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy. A cochrane systematic review of the randomised evidence. Stroke 36 905.
[Abstract/Free Full Text]
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