Analysis of safety of carotid endarterectomy in nonagenarians and the implications of frailty - A National surgical quality improvement program analysis

Abstract

Background

Carotid artery stenosis prevalence increases with age, and carotid endarterectomy (CEA) is a possible treatment option. However, nonagenarians are at high risk of experiencing postoperative complications and are often not considered surgical candidates. We aimed to identify risk factors associated with postoperative myocardial infarction (MI), stroke, and death within 30 days for nonagenarians undergoing CEA and to analyze the predictive ability of modified frailty indices (mFI) in predicting adverse outcomes for this population.

Materials and methods

This was a retrospective cohort study of patients aged 90 + years who underwent CEA from 2015 to 2019 utilizing the validated multi-institutional National Surgical Quality Improvement Program (NSQIP) vascular targeted registry. Multivariable logistic regression was used to analyze and identify factors associated with incidence of MI, stroke, and death within 30 days of surgery. The utility of 2-factor mFI consisting of functional dependence and dyspnea in predicting these complications was separately tested with univariable logistic regression.

Results

Of 191 patients meeting study criteria, 2.1 % had strokes, 3.7 % MIs, and 3.7 % died. Preoperative aspirin use (OR 0.09, 95 % CI:0.01–0.8, p = .02) was associated with lower odds of stroke. Functional status (OR 14.1, 95 % CI:1.4–151.0, p = .02) and dyspnea (OR 22.6, 95 % CI:2.1–309.3, p < .01) were associated with higher odds of MI, while statin use (OR 0.07, 95 % CI:0.007–0.5, p = .01) was associated with lower odds. Death was less frequent in elective cases (OR 0.1, 95 % CI:0.005–0.6, p = .04). The 2-factor mFI was not predictive of stroke but did predict MI and death and outperformed an existing 5-factor mFI.

Conclusion

The risk profile of CEA can be acceptable in highly select nonagenarians. Functionally independent, non-dyspneic nonagenarians with preoperative aspirin and statin use who are scheduled electively have the lowest risk for a 30-day complication following CEA. Functional dependence and dyspnea are reasonable surrogate measures of frailty and may indicate a high complication risk for nonagenarians being considered for CEA.