Features July 2012 Issue

Research Shows Carotid Artery Stenting Safe for Older Patients

When the carotid arteries, those vital pathways that carry blood from the heart to the brain, become narrowed, doctors have essentially two means of intervening and preventing a stroke. You can undergo an endarterectomy, a surgical procedure in which the artery is opened and plaque is removed, or you can have a stent put in to help keep blood flowing to the brain. Studies in recent years have shown that endarterectomy tends to be a safer option than stenting. But many patients with carotid artery disease aren’t good candidates for surgery, perhaps because they have other medical conditions that have left them especially frail, or because they have had a stroke previously, heightening their risk of a subsequent stroke following stenting.

But a recent study, presented earlier this year at the American College of Cardiology conference, found that while the risk of stroke, heart attack and death increases with age in patients with carotid artery disease, the risks are still very low in older patients (including those 85 and older) following carotid artery stent placement.

“The results of this study are consistent with the current literature that as the population ages the risk of stroke increases; however, stenting remains a safe option for many elderly patients with carotid disease,” says Cleveland Clinic interventional cardiologist Mehdi Shishehbor, MD. “The additive value of stenting in this population is its minimally invasive nature. There is no need for general anesthesia and the majority of patients can return to normal activity the next morning.”

He adds that given the association between aging and co-morbidities, such as coronary artery disease, congestive heart failure, and frailty, a less invasive approach such stenting is usually preferred. “Indeed, the Center for Medicaid and Medicare services (CMS) considers anyone over the age of 70 as appropriate for stenting regardless of whether they have symptomatic or asymptomatic carotid disease,” Dr. Shishehbor says.

Stenting advantages

Stenting is associated with lower risk of myocardial infarction (heart attack), cranial nerve damage, and wound complications in randomized clinical trials when compared to endarterectomy, Dr. Shishehbor says. However, he adds that when the risk of heart attack is low and when anatomical features make stenting high risk, endarterectomy is often the preferred approach.

“For example, individuals with heavily calcified arteries may be better off with endarterectomy,” he explains. “Interestingly, the rate of re-blockage (re-narrowing) is similar between stenting and endarterectomy, so this should not be a reason why one should undergo carotid endarterectomy.”

When intervention is necessary

Carotid artery disease can be symptomatic, such as the occasions when it is accompanied by a stroke or transient ischemic attack (TIA) or asymptomatic. Asymptomatic disease is harder to diagnose but sometimes physicians can hear particular sounds, called bruits, during a physical exam that may indicate significant carotid disease.

Additionally, smoking, known coronary artery disease, peripheral arterial disease, and diabetes are other risk factors that have been associated with carotid blockage, Dr. Shishehbor explains. “Currently, we do not routinely check for carotid disease but for high-risk patients (defined as above), this may be reasonable.

What to expect

In general, carotid stenting is similar to getting a heart catheterization, Dr. Shishehbor says. A very small tube is placed in the femoral artery in the groin. Through this tube devices are advanced up to the carotid arteries and the blockage is stented. Stents are scaffolds that push the plaque and debris to the side and open up the blood vessel for normal blood flow.

“Patients who receive stents need to be on aspirin and clopidogrel for one month, and then aspirin alone for life,” Dr. Shishehbor says. “The procedure requires a one-night admission and observation in the hospital. Most patients return to normal activity within 24 hours. Groin pain may occur for a few days but usually is minimal.”