Safety of carotid endarterectomy in the elderly and octogenarian population: a nationwide study including 80,000 patients

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INTRODUCTION: Carotid endarterectomy (CEA) is an established procedure for stroke prevention in patients with carotid artery stenosis. While CEA is considered safe in younger patients, perioperative risks in octogenarians remain debated, with current guidelines classifying the procedure as "high-risk" in this patient population. This study aimed to evaluate short-term outcomes of CEA across age groups and to assess whether comorbidity burden better predicts outcomes than chronological age. METHODS: The ACS-NSQIP database (2013-2020), was used to identify patients eligible for inclusion. The cohort was stratified based on age < 60, 60-80, and > 80 years. Propensity score matching and multivariable logistic regression were used to compare outcomes across age groups and assess predictors of 30-day complications, readmission, reoperation, non-home discharge, and mortality. Interaction analyses were performed to evaluate the combined impact of age, functional status and comorbidity (ASA classification) on outcomes. RESULTS: Of 82,427 patients, 15,111 (18%) were > 80 years. Octogenarians had significantly higher 30-day complication, readmission, reoperation, non-home discharge, and mortality rates compared with patients aged 60-80 (all p < 0.001), even after propensity matching. Logistic regression confirmed increased risk in octogenarians (aOR 1.34, 95% CI 1.27-1.42), but comorbidity burden and functional dependency were stronger predictors; severe comorbidity (ASA 4-5; aOR 2.17, 95% CI 1.91-2.47) and full dependency (aOR 2.61, 95% CI 1.89-3.59). Interaction analysis demonstrated that octogenarians with low comorbidity had risks comparable to younger patients with moderate comorbidity. CONCLUSIONS: CEA is associated with a worse risk profile among octogenarians. Nonetheless, comorbidity burden and functional status are stronger predictors of adverse outcomes, as compared to age alone. CEA can be performed safely in carefully selected octogenarians with low to moderate comorbidity, whereas severe comorbidity or dependency may represent relative contraindications. Surgical candidacy should be guided by physiological reserve and function rather than chronological age alone.

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