Editorial Comment

Carotid Stenting in the Elderly:The Opportunity is Still There

Jorge A. Belardi,* MD

Department of Interventional Cardiology andEndovascular Therapeutics, Instituto Cardiovascularde Buenos Aires, Buenos Aires, Argentina

Carotid artery revascularization reduces 5-year strokerates in patients with symptomatic carotid stenosis or inasymptomatic individuals with �80% carotid stenosis[1,2]. Although elderly patients carry an elevated risk ofprocedural complications, carotid endarterectomy (CE)has been performed successfully in selected octogenar-ians [3,4]. Over the past few years, carotid artery stenting(CAS) emerged as an alternative to CE and has beenincreasingly performed in patients with significantcomorbidities and in elderly people, owing to theSAPHIRE trial [5] and several CAS registries recentlypublished [6–8]. Particularly in the elderly population,CAS is presumed to be safer than CE, with a recentreport showing a 30-day rate of stroke or death <4% [9].In this issue of Cathetherization and CardiovascularInterventions, Grant et al. reported a large series of octo-genarians (N 5 418) undergoing CAS [10]. Of these418, 68% were asymptomatic. Thirty-day rate of strokeor death was 2.8% (asymptomatic 1.5% and symptomatic5%); stroke rate was 2.6% and death 0.5%. No doubts,the authors are to be congratulated for their pristineresults. Nonetheless, several questions arise regardingCAS in the elderly. In some series, octogenarians under-going CAS have a 3-year survival close to 50%. Thus, itis unknown whether the expected patients’ lifespanwould be long enough to derive potential benefit fromany procedure, especially for asymptomatic individuals.Additionally, these superb results observed at four highvolume centers with elite operators may not be reproduc-ible by others centers with less experience. To obtainthose results in the community, we have to expect theclinicians to select patients with the same rigor and theoperators to perform the procedure with similar technicalexpertise. The latter appears improbable since complica-tion rate is reduced with experience, and experience isdirectly related to procedural volume. To date, the valueof this procedure in the elderly population remainsuncertain, however, several ongoing trials may unravelthe role of CAS in this high risk population. In the mean-

time, it appears reasonable to reserve CAS in octogenar-ians to very experienced operators.

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Catheter Cardiovasc Interv 2010. DOI 10.1002/ccd.22345.

Conflict of interest: Nothing to report.

*Correspondence to: Jorge Belardi, M.D., Department of Interven-

tional Cardiology and Endovascular Therapeutics, Instituto Cardio-

vascular de Buenos Aires, Buenos Aires, Argentina.

E-mail: jabelardi@icba-cardiovascular.com.ar

Received 11 February 2010; Revision accepted 18 February 2010

DOI 10.1002/ccd.22522

Published online 1 March 2010 in Wiley InterScience (www.

interscience.wiley.com).

' 2010 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 75:658 (2010)