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Invited Critique
August 18, 2008

Carotid Endarterectomy as the Criterion Standard in High-Risk Elderly Patients—Invited Critique

Arch Surg. 2008;143(8):742. doi:10.1001/archsurg.143.8.742

During the next 15 years, the number of individuals older than 65 years will increase by 50% and, during the next 40 years, that group will grow by 135%. The most rapid increase will be among our oldest elderly, those older than 75 years. Furthermore, individuals older than 75 years have 5 to 6 times the stroke incidence of younger adults. Selecting the most appropriate treatment of carotid disease in this demographic group is a critically important health care issue.

Because NASCET1 and ACAS2 excluded elderly individuals from randomization, it has been assumed over the years by some, and in particular today by advocates of CAS, that elderly patients a priori are at increased risk of CEA complications and perhaps would be better served by CAS. The report by Suliman et al adds to a voluminous literature published during the past 20 years refuting that premise. In a series of 117 CEAs performed on 110 patients 75 years or older by 12 different surgeons during a 16-year period, the combined stroke and death rate was only 2.6%. These results are particularly remarkable when one considers that 50.4% of these patients underwent CEA for symptomatic carotid artery disease.

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