Surgical Intervention Among Asymptomatic Patients aged ≥ 80 with a Contralateral Carotid Occlusion Appears Selectively Warranted

Abstract

Objective:

The role of prophylactic carotid revascularization in asymptomatic patients aged ≥ 80 remains controversial. Current guidelines stipulate that asymptomatic older patients at “higher risk of stroke” on best medical therapy may still benefit from carotid intervention. Specifically, there is a widespread perception that a contralateral internal carotid artery(ICA) occlusion may confer an increased anatomic stroke risk, thus creating a surgical dilemma, particularly among older patients. The purpose of this analysis was to determine whether asymptomatic patients aged ≥ 80-years derive a stroke or survival benefit from prophylactic carotid revascularization in the setting of a contralateral ICA occlusion.

Methods:

We analyzed asymptomatic patients with a contralateral occlusion who underwent carotid endarterectomy(CEA) or transcarotid artery revascularization(TCAR) using the Vascular Quality Initiative(VQI) database. Our primary exposure was age(< 80-years vs. ≥ 80-years). Primary outcomes included 30-day stroke, 30-day mortality, and 5-year survival. Logistic regression, Cox-regression, and propensity-score matching were used for risk adjustment.

Results:

We identified a total of 3,486 asymptomatic patients who underwent carotid surgery(CEA: 72.0%, TCAR: 28.0%) in the setting of a contralateral carotid occlusion; 14.7% were aged ≥ 80-years, 29.5% were female, and 91.1% were white. Older patients had overall similar comorbidities compared to younger patients, but were more likely to undergo TCAR(< 80-years: 26.7% vs. ≥ 80-years: 35.2%). The unadjusted 30-day stroke risk was similar between age groups(< 80-years: 2.2%, vs. ≥ 80-years: 1.0%, p = .26); however, mortality was 2-fold higher among patients aged ≥ 80(< 80-years: 0.9% vs. ≥ 80-years: 2.3%, p = .04). The unadjusted risk of 30-day stroke or death was 2.9% for patients patients aged < 80-years and 4.0% for those ≥ 80-years(p = .34). Propensity score matching yielded 511 matched pairs. The composite endpoint of stroke or death in the matched cohort was 4.6% for patients < 80-years and 4.0% for those ≥ 80-years(p = .73). The 18-month stroke-free survival was 81.2%[95%CI 76–87%] in patients < 80-years and 78.0%[73–84%] in those ≥ 80-years(log-rank p-value = .4;). 5-year survival was similar between groups(< 80-years: 84.6%[80.2–89.3%], ≥ 80-years: 80.8%[76.2–85.8%]; log-rank p-value = .4).

Conclusions:

Perioperative outcomes in asymptomatic patients aged ≥ 80 with a contralateral ICA occlusion were similar to those in patients aged < 80, validating the rationale to consider surgery in eligible older patients at elevated stroke risk. Notably, both younger and older patients experienced composite perioperative stroke or death rates exceeding the current SVS safety benchmark of 3% in asymptomatic patients. Therefore, based on these results, carotid intervention should be selectively applied in patients aged ≥ 80 within this high-risk subgroup.

Table of Contents Summary

Asymptomatic patients aged ≥ 80 with contralateral ICA occlusion experienced similar perioperative and mid-term outcomes following carotid revascularization compared to younger patients. Age alone should not preclude consideration of surgical intervention in this high-risk subgroup, though careful patient selection remains paramount.

Introduction

The role of prophylactic carotid revascularization, particular carotid endarterectomy (CEA) among asymptomatic patients aged ≥ 80 remains a topic of ongoing debate. Current guidelines emphasize the importance of individualized treatment approaches for older patients, especially those at longitudinal increased risk of stroke, despite optimal medical therapy. While the Society for Vascular Surgery (SVS) and European Society for Vascular Surgery (ESVS) agree on revascularization for select high-risk asymptomatic patients, there is no clear consensus on whether patients aged ≥ 80 derive a benefit from surgery, particularly when they have a contralateral internal carotid artery (ICA) occlusion.^{1, 2}

Notably, the management of asymptomatic patients aged ≥ 80 with contralateral ICA occlusion is especially contentious. Patients aged ≥ 80 patients were not included in the historical seminal randomized trials that have shaped contemporary perioperative decision-making for carotid revascularization.³ Furthermore, patients aged ≥ 80 are known to experience increased risks of perioperative stroke and death while having shorter life expectancies, thereby reducing the derived therapeutic window from carotid intervention.⁴ Despite these challenges, a contralateral ICA occlusion has been previously reported to potentially confer an increased long-term stroke risk, suggesting that prophylactic revascularization might still offer benefit in carefully selected patients.^{3, 5} This controversy is further perpetuated by a lack of robust evidence to guide treatment in this older cohort. Given our aging population, it is accordingly important to clarify whether prophylactic carotid revascularization in patients aged ≥ 80 with contralateral ICA occlusion offers a stroke or survival benefit.^{6, 7}

This study aims to evaluate the outcomes of asymptomatic patients aged ≥ 80 undergoing a carotid intervention with a documented contralateral occlusion and compare results to younger patients. In doing so, we hope to inform evidence-based decision-making in this high-risk population.

Methods

Data Source and Patient Selection.

Our a priori working hypothesis was that patients aged ≥ 80 patients would have higher stroke/death risk at 30-days compared to younger subjects after carotid revascularization. To investigate this postulate, we utilized the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) national carotid registry database, which includes detailed procedural and patient-level data from over 600 centers across the United States. Patients undergoing elective carotid revascularization from January 2003 to February 2024 were reviewed. The study included asymptomatic adults (≥ 18-years) who underwent carotid endarterectomy (CEA) or trans-carotid artery revascularization (TCAR; which began being captured in the SVS VQI carotid registry after 2016). Eligible patients had asymptomatic, ipsilateral internal carotid artery (ICA) stenosis ≥ 80% as reported in the VQI registry and a contralateral ICA occlusion that was confirmed by imaging (CT and/or duplex ultrasound).

Asymptomatic status was defined as the absence of prior stroke, transient ischemic attack (TIA), or amaurosis fugax. Exclusion criteria included symptomatic and/or non-elective presentations, bilateral procedures, or cases with incomplete data on key demographic or clinical variables. Additionally, we intentionally excluded transfemoral carotid artery stenting (TF-CAS) due to the known higher risk of perioperative stroke and death among patients aged ≥ 80.⁸ After applying these inclusion and exclusion criteria, the remaining patients were stratified into two cohorts based on age: < 80-years (‘patients aged < 80’ cohort) and ≥ 80-years (‘patients aged ≥ 80’ cohort) (Figure 1). This study was deemed exempt by the University of Florida Institutional Review Board (IRB#145–2024).

Figure 1:

Study Overview and Patient inclusion

Outcomes and Definitions.

The primary outcomes were 30-day stroke rate, 30-day mortality, and the composite endpoint of stroke or death within 30 days. Survival was assessed up to five years post-surgery using the SVS-VQI linkage to the Social Security Death Index Masterfile. Notably, all out of hospital mortality analyses were truncated to procedures performed up until 2021 because the provided SVS-VQI data suggests that routine SSDI checks were not performed after 2022 in the dataset provided (e.g., for 27% of 2022 procedures, 46% of 2023 procedures and 53% of 2024 procedures in the dataset, the survival time = postoperative length of stay; LOS). Postoperative stroke was defined as any new persistent neurological deficit (ipsilateral or contralateral location) that was confirmed through clinical evaluation and/or imaging. 30-day mortality events included death from any cause that was documented within this time period. Secondary outcomes included postoperative myocardial infarction (MI), cranial nerve injury (CNI), and other procedural complications which have been defined by SVS-VQI and are available upon request (www.vqi.org).

Statistical Analyses.

Continuous variables were reported as means with standard deviations or medians with interquartile ranges and groups were compared using independent t-tests or Mann-Whitney U tests, as appropriate. Categorical variables were expressed as percentages and analyzed using chi-squared or Fisher’s exact tests. Kaplan-Meier methods were used to assess the univariate effect of age on long-term survival and freedom from stroke.

Mixed-effects logistic and Cox regression and propensity matching were used to assess the effect of age ≥ 80-years on outcomes (including 30-day mortality, 30-day stroke, 30-day stroke/death and long-term mortality). In the Cox regression model, covariates included patient gender, race, ethnicity, body mass index (BMI), primary insurer, Rural-Urban Commuting Area (RUCA) code, Area Deprivation Index (ADI) rank, preoperative presence of coronary artery disease (CAD), congestive heart failure (CHF), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), hypertension (HTN), renal dysfunction (creatinine≥1.7 mg/dl or on dialysis), preoperative hemoglobin (Hgb: ≥12, 10–12 or <10 g/dl), abnormal stress test, transfer status, history of coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), carotid endarterectomy (CEA) or carotid artery stent (CAS) and major amputation, preoperative medications (aspirin: ASA, antiplatelets including clopidogrel, statin, anticoagulants, and betablockers), preoperative classification of anatomical high risk (defined by presence of any one or more of the following: tracheal stoma, prior neck surgery, contralateral laryngeal nerve palsy, common carotid artery lesion proximal to the clavicle), anesthesia type, year of surgery and surgery type (CEA or TCAR). Notably, lesion calcification severity is only recorded for SVS-VQI CAS procedures and not CEA procedures, so this covariate was not modeled in the analysis.

To avoid overfitting, the number of covariates was reduced for 30-day outcomes to ensure at least 10 events/covariate. All models included a random effect for treating center to account for the clustering of observations on hospitals. Data for all covariates was missing in <3% of cases, with 91% of covariates 100% complete or missing in <1% of cases. All missing data was imputed with the mean or the mode before modeling. Nearest-neighbor propensity matching with a caliper width of 0.1 standard deviations of all propensity scores was used to pair patients ≥ 80-years of age with younger patients. Patients were matched on all covariates listed above. Balance in the matched cohort was assessed using the absolute standardized mean difference (ASMD), with ASMD <0.1 for all matching factors considered acceptable. Binomial outcomes for age groups in the matched cohort were compared using logistic regression with robust sandwich estimators to account for the dependency within matched pairs. Kaplan-Meier methods were used to compare groups on long-term survival.

All analyses were performed using the R statistical software package (V.4.4.1, The R Foundation for Statistical Computing). A p-value < .05 was considered significant.

Results

Patient Demographics and Baseline Characteristics.

We identified a total of 3,486 patients who met our inclusion and exclusion criteria, with 2,973 in the patients aged < 80 cohort (85.3%) and 513 in the patients aged ≥ 80 group (14.7%, Figure 1). Patients aged ≥ 80 were significantly more likely to have Medicare insurance (63.9% vs. 48.3%, p < .001) and had a lower BMI (23.1 vs. 26.8, p < .001) compared to patients aged < 80. Overall, comorbidities were comparable or even somewhat less prevalent in the patients aged ≥ 80 group (e.g., COPD/DM), with the exception of a trend toward higher rates of congestive heart failure (17.2% vs. 14.0%, p = .07). There was a trend towards higher rates of anatomic high-risk features among patients aged ≥ 80 (age ≥80-years: 27% vs. patients aged < 80, age < 80-years: 23%, p = .06) (Table I).

Table 1.

Demographics Among Octogenarians and Non-Octogenarians undergoing Carotid Revascularization

Age Categories*
Covariates	Age < 80	Age > 80	P-value
	2973 (85%)	513 (15%)
TCAR	794 (26.7)	181 (35.2)	<.0001
Race White, n (%)	2706 (91.1)	467 (91.0)	0.975
Current Smoker, n, %	1072 (36.1)	49 (9.6)	< 0.0001
BMI > 31, n %	799 (26.9)	72 (14.0)	<0.0001
Medicare	946 (32)	90 (18)	< 0.0001
Comorbidities
CAD	1116 (37.6)	209 (40.8)	.168
CHF	417 (14.0)	88 (17.2)	.067
COPD	845 (28.5)	123 (24.0)	.037
DM	1084 (36.5)	166 (32.4)	.073
CKD stage IV	215 (7.3)	43 (8.5)	.360
ASA Class 4/5	461 (18.5)	99 (22.6)	.048
Anatomic High-Risk Features	692 (23.4)	139 (27.3)	.064

Combined data, common variables by age. Continuous variables presented as mean (SD); median [IQR] (range); categorical variables presented as N(%). P-values are the results of Mann-Whitney tests (continuous variables) or Fisher's exact tests.

Procedural characteristics revealed a higher utilization of TCAR in patients aged ≥ 80 (35.2%) than in patients aged < 80 (26.7%, P < .0001) (Table II). In general, cranial nerve injury was more common for patients undergoing CEA but did not differ significantly between age cohorts when further controlling for repair type. Secondary outcomes demonstrated no other significant differences between the groups; however, there was a trend towards longer LOS in the patients aged ≥ 80 group (mean LOS in days, 2.1 vs. age < 80-years, 1.9, p = .08).

Table 2.

Procedural Outcomes Among Octogenarians and Non-Octogenarians undergoing Carotid Revascularization

Age Categories*
Covariates	Age < 80	Age > 80	P-value
	2973 (85%)	513 (15%)
TCAR	794 (26.7)	181 (35.2)	<.0001
Total Procedure Time (Min)	113 (60.3)	103 (51.4)	.001
IV Meds for Hypertension	422 (14.8)	69 (14.4)	.889
IV Meds for Hypotension	502 ( 16.9)	90 ( 17.6)	.702
Any Post op Complication	150 (5.0)	27 (5.3)	.828
Cranial Nerve Injury
Transient	53 (1.9)	2 (0.4)
Present at discharge	2 (0.1)	0 (0)	.040
Post op MI	17 (0.3)	2 (0.2)	0.40
Post op Surgical Site Infection	2 (0.1)	(0))	1
Post op Stroke	33 (1.1)	2 (0.4)	.155
Post op TIA	19 (0.6)	6 (1.2)	.249
Death in Hospital	10 (0.3)	4 (0.8)	.139

Combined data, common variables by age. Continuous variables presented as mean (SD); median [IQR] (range); categorical variables presented as N(%). P-values are the results of Mann-Whitney tests (continuous variables) or Fisher's exact tests.

Univariate Analysis.

The 30-day stroke rate did not differ significantly between the cohorts, with a stroke rate among patients aged ≥ 80 of 1.0% compared to 2.2% in patients aged < 80 (p = .26). However, 30-day mortality after carotid revascularization was higher for patients aged ≥ 80, at 2.3%, compared to 0.9% in the patients aged < 80 group (p = .04) (Table III).

Table 3.

Unadjusted 30-day Outcome Rates Among Octogenarians and Non-Octogenarians undergoing Carotid Revascularization

Age Categories*
Covariates	Age < 80	Age > 80	P-value
	2973 (85%)	513 (15%)
30-day Mortality	18 (0.9)	8 ( 2.3)	.042
30-day Stroke	39 (2.2)	3 (297)	.262
30-day Stroke or Mortality Composite	48 (2.9)	11 (4.0)	.343

Mid-term freedom from stroke or death.

Unadjusted Kaplan-Meier analysis demonstrated lower out of hospital survival among patients aged ≥ 80 compared to patients aged < 80 at 30 days (≥ 80-years: 97.7% [95% CI: 96.2–99.3%] vs. < 80-years: 99.1% [98.8–99.5%]), 1-year (92.0% [89.2–94.9%] vs. 94.8% [93.8–95.7%]), and 5-years (80.9% [76.2–85.8%] vs. 86.9% [85.2–88.6%]; log-rank p = .007, Figure 2A). However, postoperative freedom from stroke was comparable between groups (Figure 2B). Unadjusted rates of freedom from the composite endpoint of stroke or death favored patients aged < 80 (Figure 2C).

Fig 2.

Kaplan-Meier estimates of (A) freedom from stroke, (B) stroke or death, and (C) long-term survival among octogenarians and Non-Octogenarians

To account for potential confounding factors, mixed-effects Cox and logistic regression analyses were performed as described in the methods section. Age ≥ 80-years was associated with a higher odds of 30-day mortality (OR: 2.8, 95% CI: 1.20–6.56, p = .02). However, no significant differences were observed for 30-day stroke (OR: 0.46, 95% CI: 0.14–1.5, p = .2) or the composite of 30-day stroke/death (OR: 1.4, 95% CI: 0.7–2.8, p = .3). For long-term survival, age ≥ 80-years corresponded to a hazard ratio of 1.5 (95% CI: 1.1–2.0, p = .01).

Propensity matched analysis.

A total of 511 patients aged ≥ 80 were matched to 511 patients aged < 80 patients based on propensity scores (Appendix Table I). Matching criteria included demographic variables, comorbidities, procedural characteristics, and anatomic risk factors. Covariate balance between the groups was achieved, as demonstrated by standardized mean differences <0.1 across all matched variables (Appendix Figure I). In the matched cohort, 30-day mortality was similar (age < 80-years, 1.4% vs. age ≥80-years, 2.3%; p= .4). Similarly, the composite endpoint of 30-day stroke or death occurred in 4.0% of patients aged ≥ 80 versus 4.6% of patients aged < 80 (p = .73). When examining mid-term freedom from stroke outcomes, similar outcomes were detected (Figure 3A & B). Finally, long-term survival analysis showed no significant differences between matched cohorts (5-year Kaplan-Meier survival: 80.8%[76.2–85.8%] for patients aged ≥ 80 vs. 84.6% [80.2–89.3%] for patients aged < 80; log-rank p = .4, Figure 3C).

Fig 3.

Kaplan-Meier estimates of (A) freedom from stroke, (B) stroke/death, and (C) long-term survival among a matched cohort octogenarians and Non-Octogenarians

Sensitivity Analysis. Procedure type

Given the possibility of variable outcomes based on procedure type as a potential confounding variable we performed a sensitivity analysis In order to ascertain whether significant differences between TCAR and CEA were present. In our univariate analysis, patient undergoing TCAR were more likely to be older, have Medicare insurance, as well as higher rates of CAD ( Supplemental Table A). However, in our multivariate analysis, there were no significant differences between TCAR and CEA for 30-day death, ( OR 0.61, P=0.40), 30-day stroke ( OR 0.66, P= 0.3), or a composite of stroke and death (OR 0.59, P= 0.20) ( Supplemental Table B). In short, our global results are a weighted average of the two procedures, with results for CEA contributing about 70% of the weight.

Sensitivity Analysis. Age

To better understand whether patients aged ≥ 90 were influencing and potentially skewing results, we performed an additional sensitivity analysis. We first identified how many patients in our cohort were aged ≥ 90, which included 23 of the 513 patients in the older than 80 cohort, with similar baseline characteristics between patients aged 80–89 and ≥ 90 (supplemental table C). In our multivariate analysis, where we compared the initial cohort of all patients aged ≥ 80 to only those 80–89, no qualitative differences were observed with similar effect sizes between groups, hence demonstrating that the results were not being driven by a large number of patients ≥ 89 with significantly worse outcomes( Supplemental table D).

Discussion

In this retrospective cohort study, we demonstrate that carotid intervention, including both CEA and TCAR, in asymptomatic patients aged ≥ 80 with contralateral internal carotid artery (ICA) occlusion had similar perioperative and mid-term outcomes to younger patients aged < 80. Specifically, this multicenter national analysis documented that patients aged ≥ 80 experienced similar perioperative stroke rates compared to younger individuals and achieved comparable long-term survival at five years, despite historical perceptions to the contrary. Although 30-day mortality was slightly elevated in the older cohort, the absolute unadjusted difference was small (<1.5%), and no significant differences were observed in the composite endpoint of stroke or death after propensity score matching. Notably, the composite 30-day stroke and death rates in both groups exceeded the SVS guideline benchmark of 3%. These findings potentially suggest that age alone should not disqualify eligible asymptomatic patients for carotid revascularization and underscores the importance of incorporating anatomical and physiological risk factors into the shared decision-making process to deliver optimal care to older patients.

Previous literature has emphasized the challenges of carotid revascularization in elderly patients, largely due to a concomitant prevalence of comorbidities and increased procedural risks.^{8, 9} Interestingly, our analysis showed that many cardiovascular risk factors commonly seen among older patients were either similar or less prevalent in the patients aged ≥ 80 cohort. This suggests that providers in the VQI appear to carefully select patients aged ≥ 80 patients with asymptomatic high-grade ICA stenosis and contralateral occlusion for revascularization.

The Centers for Medicare and Medicaid Services (CMS) has previously defined high-risk factors when stratifying patients meeting criteria for carotid artery stenting versus carotid endarterectomy.^{10, 11} Among these high-risk features, age ≥ 80-years, as well as contralateral occlusion were both identified as important covariates when considering carotid revascularization. Not surprisingly, these factors remain associated with adverse outcomes, and prior studies, including those from Nejim et al., have shown that patients aged ≥ 80 undergoing CEA experience increased rates of perioperative stroke and mortality compared to younger patients, highlighting the importance of careful patient selection.⁷ Similarly, data from the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) suggest that while carotid revascularization was effective at reducing stroke risk in older patients, the associated procedural risks partially diminished this benefit.¹² In line with these findings, the Society for Vascular Surgery (SVS) has recommended that asymptomatic patients undergoing carotid intervention achieve a perioperative stroke or death risk below 3% to accordingly justify the procedure.¹³ It has remained historically uncertain whether patients aged ≥ 80 patients can reliably meet this clinical outcome benchmark thus perpetuating the ongoing clinical dilemma of whether to offer prophylactic revascularization.

Unlike previous studies, our analysis included patients undergoing both CEA and TCAR, which allowed us to capture a broader spectrum of procedural outcomes in the elderly population. TCAR, a relatively newer and less invasive technique, was more frequently used in patients aged ≥ 80 than in patients aged < 80 within our study cohort, reflecting a trend toward employing this technique in older patients. This finding is consistent with Schermerhorn et al., who reported favorable outcomes with TCAR compared to TF-CAS and CEA, particularly in older patients with multiple comorbidities.¹⁴ While our results showed that both patients aged ≥ 80 and patients aged < 80 undergoing carotid revascularization experienced composite stroke/mortality rates that exceeded SVS safety benchmarks, these findings emphasize that patients with contralateral occlusion, regardless of age, face increased procedural risks.

It is estimated that 8% to 10% of patients with carotid artery stenosis will present with a contralateral carotid occlusion (CCO).^{3, 15, 16} The decision to offer prophylactic carotid revascularization to an asymptomatic patient with CCO typically relies on evaluating the patient’s estimated long-term stroke risk, balancing it against the perioperative stroke risk, anticipated life expectancy, and individual patient preferences. The natural history of patients with known ICA occlusion and contralateral asymptomatic carotid stenosis has historically been reported to have a combined risk of late stroke or TIA of 6–10% per year.^17–20 However, the clinical impact of CCO on outcomes of carotid revascularization is less defined. Some studies have reported that CCO increases the odds of perioperative adverse events after CEA by 50–70%,^{3, 21, 22} while others find no differences in early stroke or death rates between patients with or without contralateral ICA occlusion.^{6, 23} Interestingly, CAS has been reported to be a reasonable (or even preferred) strategy to carotid revascularization in selected patients with CCO.²⁴

Providers face an especially challenging clinical dilemma in this scenario because CCO presents a unique combination of elevated stroke risk and unclear revascularization benefits, especially in asymptomatic older patients. This complexity is amplified when treating patients aged ≥ 80, who are already known to have higher periprocedural risks with carotid revascularization. Accordingly, balancing the heightened risks against the potential for long-term stroke risk prevention requires careful consideration of the patient’s frailty, comorbidity, lesion morphology, and life expectancy which underscores the need for nuanced, individualized shared decision-making for subjects presenting with this pattern of disease.

Additionally, our study contributes to the existing literature by demonstrating that careful selection of asymptomatic patients aged ≥ 80 for carotid intervention, particularly those with significant anatomical risk factors such as contralateral ICA occlusion, can result in outcomes comparable to those of younger patients. Unlike prior studies that focused primarily on CEA outcomes, our analysis highlights the additional potential of TCAR to optimize perioperative safety for elderly, high-risk patients. Moreover, our findings suggest that long-term survival in patients aged ≥ 80 who undergo carotid revascularization is similar to that of patients aged < 80, reinforcing the need for individualized decision-making rather than relying solely on chronological age. Additionally, it should be highlighted that this analysis was not intended to differentiate the merits and pitfalls of either procedure, but rather that the cumulative outcomes of either revascularization option was acceptable.

This is of particular importance given recent recommendations from a multidisciplinary expert panel, which emphasized that the management of asymptomatic carotid stenosis—especially in older or high-risk patients—should be individualized rather than guided by uniform protocols. In their position statement, Paraskevas et al. highlight the need to integrate anatomical risk, life expectancy, comorbidities, patient frailty, imaging characteristics, and personal preferences into treatment decisions.²⁵ They advocate for a tailored approach to revascularization, particularly in populations historically underrepresented in randomized trials, such as patients aged ≥ 80. Our findings support this framework by demonstrating that carefully selected asymptomatic patients aged ≥ 80 with contralateral carotid occlusion can achieve perioperative and mid-term outcomes similar to younger patients, reinforcing the importance of patient-centered decision-making in this complex clinical scenario. These findings also highlight that providers appear to be doing a good job selecting patients who stand to benefit from prophylactic carotid intervention.

In addition to offering patients a more individualized approach to the management of carotid disease, it is essential that shared decision-making is not solely based on older data from earlier landmark trials such as ACAS and ACST. Best medical therapy (BMT) has evolved significantly since the publication of those foundational studies. Although the true comparative effectiveness of contemporary BMT alone versus carotid intervention plus BMT remains under investigation, the results of the ongoing CREST-2 trial will provide clinicians and patients alike, critical evidence to support more informed, evidence-based, and patient-centered decisions.²⁶

We acknowledge several important limitations in our study. The retrospective design and reliance on registry data introduce potential selection bias and residual confounding, even with the use of logistic and Cox proportional hazard modeling, as well as propensity score matching to adjust for baseline differences. Furthermore, the absence of detailed anatomical variables in the CEA cohort prevented us from better examining any lesion morphological characteristics, which may have influenced clinical decision making and procedure selection. Given this lack of granularity, we are unable to identify which specific characteristics most influenced individualized decision making; however, future work will focus on exploring these nuanced characteristics. Moreover, the truncation of the survival analysis at five years, due to incomplete follow-up data, limits our ultimate ability to evaluate longer-term outcomes. Furthermore, we lack a longitudinally followed cohort of unoperated patients to estimate the natural history of stroke and death without carotid revascularization, although prior studies have demonstrated an increased annualized stroke risk in patients with CCO. The modest sample size and event rates leave the study vulnerable to type II error. While we did not directly compare CEA and TCAR, sub-analysis revealed no significant differences in outcomes between the procedures, which we felt justified their aggregation in our analysis. Additionally, functional outcomes and quality-of-life measures—critical for assessing the true benefit of carotid intervention in elderly patients—were not captured. Addressing these gaps in future research, including prospective studies or randomized controlled trials, will help refine patient selection criteria and guide clinical decision-making more effectively.

Conclusion

In conclusion, our study demonstrates that perioperative outcomes after carotid revascularization in asymptomatic patients aged ≥ 80 with contralateral ICA occlusion are comparable to those of patients aged < 80. Although both age groups exceeded the SVS safety benchmarks for composite stroke and mortality rates, our findings support the selective use of carotid intervention in this high-risk population. These results underscore the importance of individualized decision-making based on physiological and anatomical factors rather than chronological age, further contributing to the growing evidence and guideline recommendations for tailored surgical strategies.

Supplementary Material

Appendix

Appendix Figure 1. Age-matched Absolute Standardized Mean Difference Plot among Patients aged ≥ 80 and patients aged < 80

Appendix Table 1. Demographics among a matched cohort of Patients aged ≥ 80 and Patients aged < 80

Supplemental Table A. Univariate results, TCAR vs CEA

Supplemental Table B. Multivariable results for TCAR vs CEA

Supplemental Table C. Univariate results, patients aged 80–89 vs ≥90

Supplemental D : Multivariable results among original cohort of patients ≥ 80 compared to excluding patients ≥ or = 90.

ARTICLE HIGHLIGHTS.

Type of Research:

• Multicenter retrospective cohort study using the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry data

Key Findings:

• Among 3,486 asymptomatic patients undergoing carotid intervention with contralateral ICA occlusion, 30-day stroke rates were similar between those aged ≥ 80 and those < 80.

• After risk adjustment via propensity matching, older patients (≥ 80) had comparable perioperative stroke or death rates (4.0% vs 4.6%, p=.73) and similar 5-year survival to younger patients.

• Both groups exceeded the current Society for Vascular Surgery (SVS) benchmark of 3% for 30-day stroke or death in asymptomatic patients.

Take home Message:

• Asymptomatic patients aged ≥ 80 with contralateral ICA occlusion experienced similar perioperative and mid-term outcomes following carotid revascularization compared to younger patients.

• Age alone should not preclude consideration of surgical intervention in this high-risk subgroup, though careful patient selection remains paramount.