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Carotid artery disease in older people: clinical features and management

  • A Ross Naylor (a1)


The ‘take home’ messages for managing elderly patients with symptomatic carotid disease are that they need to be investigated as soon as possible after onset of the index event and that someone has to take active responsibility for ensuring that risk factor control and best medical therapy is started as soon as possible. In this modern era, patients suffering a transient ischaemic attack/minor stroke should be seen in dedicated, rapidly accessible single visit clinics, and those found to have significant carotid disease should generally be admitted and undergo expedited carotid endarterectomy (CEA) unless contra-indicated. Every centre should now aim to be performing carotid surgery within 14 days of onset of symptoms, with this threshold likely to become even shorter in the future. The current culture of allowing delays to treatment should be considered unacceptable. Evidence suggests that the risk of procedural stroke is lower in higher volume centres and this should be considered when planning referrals. Recently symptomatic elderly patients deemed unfit for CEA should be considered for carotid artery stenting (CAS), but with the caveat that this may be associated with an increased risk of procedural stroke. In this situation, every patient should be considered on an individual basis and no symptomatic patient should be denied access to surgery simply on the grounds of age. Meta-analyses of data from the international trials have clearly shown that patients aged >75 years gain considerably more benefit from CEA than any other age group. In contrast, there is no compelling evidence that patients aged >75 years with asymptomatic carotid artery disease benefit from CEA or CAS. For this category of patients, risk factor control and best medical therapy should remain the first line of management.


Corresponding author

Address for correspondence: Professor A.R. Naylor, Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK. Email:


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1Sprigg, N, Machili, C, Otter, ME, Wilson, A, Robinson, TG. A systematic review of delays in seeking medical attention after transient ischaemic attack. JNNP 2009; 80: 871–75.
2Giles, MF, Flossman, E, Rothwell, PM. Patient behaviour immediately after transient ischemic attack according to clinical characteristics, perception of the event, and predicted risk of stroke. Stroke 2006; 37: 1254–60.
3The National Audit Office. Reducing brain damage: Faster access to better stroke care. Available at:
4Nguyen-Huynh, MN, Fayad, P, Gorelick, PB, Claiborne-Johnstone, S. Knowledge and management of transient ischaemic attacks among US primary care physicians. Neurology 2003; 61: 1455–56.
5Rothwell, PM, Warlow, CP. Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 2005; 64: 817–20.
6Giles, MF, Rothwell, PM. Risk of stroke after transient ischaemic attack: A systematic review and meta-analysis. Lancet Neurol 2007; 6: 1063–72.
7Wu, CM, McLaughlin, K, Lorenzetti, DL, Hill, MD, Manns, BJ, Ghali, WA. Early risk of stroke after transient ischaemic attack: A systematic review and meta-analysis. Arch Int Med 2007; 167: 2417–22.
8Johnston, SC, Rothwell, PM, Nguyen-Huynh, N, Giles, MF, Elkins, JS, Bernstein, AL, Sidney, S. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283–92.
9Chandratheva, A, Mehta, Z, Geraghty, OC, Marquardt, L, Rothwell, PM. Population based study of risk and predictors of stroke in the first few hours after a TIA. Neurology 2009; 72: 1941–47.
10Ois, A, Cuadrado-Godia, E, Rodriguez-Campello, A, Jimenez-Conde, J, Roquer, J. High risk of early neurological recurrence in symptomatic carotid stenosis. Stroke 2009; 40: 2727–31.
11Fairhead, JF, Mehta, Z, Rothwell, PM. Population based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology 2005; 65: 371–75.
12Naylor, AR. The importance of initiating ‘best medical therapy’ and intervening as soon as possible in patients with symptomatic carotid artery disease: Time for a radical rethink of practice. J Cardiovasc Surg 2009; 50: 773–82.
13Rothwell, PM, Giles, MF, Chandratheva, A, Marquardt, L, Geraghty, O, Redgrave, JN, Lovelock, CE, Binney, LE, Bull, LM, Cuthbertson, FC, Welch, SJ, Bosch, S, Alexander, FC, Silver, LE, Gutnikov, SA, Mehta, Z; Early use of Existing Preventive Strategies for Stroke (EXPRESS) study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): A prospective population based sequential comparison. Lancet 2007; 370: 1432–42.
14Luengo-Fernandez, R, Gray, AM, Rothwell, PM. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS Study): A prospective population based sequential comparison. Lancet Neurol 2009; 8: 235–43.
15Rothwell, PM, Eliasziw, M, Gutnikov, SA, Fox, AJ, Taylor, DW, Mayberg, MR, Warlow, CP, Barnett, HJM; for the Carotid Endarterectomy Trialists Collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361: 107–16.
16Rothwell, PM, Eliasziw, M, Gutnikov, SA, Warlow, CP, Barnett, HJM; for the Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363: 915–24.
17Rothwell, PM, Eliasziw, M, Gutnikov, SA, Warlow, CP, Barnett, HJM. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and minor stroke. Stroke 2004; 35: 2855–61.
18European Carotid Surgery Trialists Collaborative Group. MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70–99%) or mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–43.
19North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high grade stenosis. NEJM 1991; 325: 445–53.
20Mayberg, MR, Wilson, SE, Yatsu, F, Weiss, DG, Messina, L, Hershey, LA, Colling, C, Eskridge, J, Deykin, D, Winn, HR; for the Veterans Affairs Co-operative Studies Programme 309 Trialist Group. Carotid endarterectomy and prevention of cerebral ischaemia in symptomatic carotid stenosis. JAMA 1991; 266: 3289–94.
21Naylor, AR. Occam's Razor: Intervene early to prevent more strokes. J Vasc Surg 2008; 48: 1053–59.
23The National Stroke Strategy. Available at:
24Salem, MK, Sayers, RD, Bown, MJ, Eveson, DJ, Robinson, TG, Naylor, AR. Rapid access carotid endarterectomy can be performed without a significant increase in the procedural risk. Eur J Vasc Endovasc Surg (in press).
25Wardlaw, JM, Chappell, FM, Stevenson, M, De Nigris, E, Thomas, S, Gillard, J, Berry, E, Young, G, Rothwell, P, Roditi, G, Gough, M, Brennan, A, Bamford, J, Best, J. Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess 2006; 10: iiiiv, ix–x, 1–182.
26Brown, C, Naylor, AR. Improving the provision of carotid endarterectomy in line with UK Government targets will require more than motivated surgeons! Ann Royal Coll Surg Eng 2009; 91: 326–29.
27Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421–28.
28Asymptomatic Carotid Surgery Trial Collaborators. The MRC Asymptomatic Carotid Surgery Trial (ACST): Carotid endarterectomy prevents disabling and fatal carotid territory strokes. Lancet 2004; 363: 1491–502.
29Liapis, CD, Bell, PRF, Mikhailidis, D, Sivenius, J, Nicolaides, A, Fernandes, , Fernandes, J et al. ESVS Guidelines. Invasive Treatment for Carotid Stenosis: Indications, Techniques. Eur J Vasc Endovasc Surg 2009; 37: S119.
30Naylor, AR. Transatlantic Debate: The majority of patients with asymptomatic carotid disease do not require intervention and are better treated medically: Pro. Eur J Vasc Endovasc Surg 2010; 40: 274–81.
31Ederle, J, Dobson, J, Featherstone, RL, Gaines, PA, Beard, JD, Venables, GS; on behalf of the CAVATAS Investigators. Endovascular treatment with angioplasty or stenting versus endarterectomy in patients with carotid artery stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): Long term follow-up of a randomised trial. Lancet Neurol 2009; 8: 898907.
32Mas, JL, Chatellier, G, Beyssen, B, Branchereau, A, Moulin, T, Becquemin, JP, Larrue, V, Lièvre, M, Leys, D, Bonneville, JF, Watelet, J, Pruvo, JP, Albucher, JF, Viguier, A, Piquet, P, Garnier, P, Viader, F, Touzé, E, Giroud, M, Hosseini, H, Pillet, JC, Favrole, P, Neau, JP, Ducrocq, X; EVA-3S Investigators. Endarterectomy versus stenting in patients with severe symptomatic stenosis. NEJM 2006; 355: 1660–71.
33SPACE Collaborators. Stent Protected Angioplasty versus Carotid Endarterectomy in symptomatic patients: 30 days results from the SPACE Trial. Lancet 2006; 368: 1239–47.
34International Carotid Stenting Study investigators, Ederle, J, Dobson, J, Featherstone, RL, Bonati, LH, van der Worp, HB, de Borst, GJ, Lo, TH, Gaines, P, Dorman, PJ, Macdonald, S, Lyrer, PA, Hendriks, JM, McCollum, C, Nederkoorn, PJ, Brown, MM. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid artery stenosis (International Carotid Stenting Study): An interim analysis of a randomised controlled trial. Lancet 2010; 375: 985–97.
35Brott, TG, Hobson, RW 2nd, Howard, G, Roubin, GS, Clark, WM, Brooks, W, Mackey, A, Hill, MD, Leimgruber, PP, Sheffet, AJ, Howard, VJ, Moore, WS, Voeks, JH, Hopkins, LN, Cutlip, DE, Cohen, DJ, Popma, JJ, Ferguson, RD, Cohen, SN, Blackshear, JL, Silver, FL, Mohr, JP, Lal, BK, Meschia, JF; CREST Investigators. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Engl J Med 2010; 363: 1123.
36Bonati, LH, Jongen, LM, Haller, S, Flach, HZ, Dobson, J, Nederkoorn, PJ, Macdonald, S, Gaines, PA, Waaijer, A, Stierli, P, Jäger, HR, Lyrer, PA, Kappelle, LJ, Wetzel, SG, van der Lugt, A, Mali, WP, Brown, MM, van der Worp, HB, Engelter, ST; ICSS-MRI study group. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: A substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9: 353–62.
37Schnaudigel, S, Groschel, K, Pilgram, SM, Kastrup, A. New brain lesions after carotid stenting versus carotid endarterectomy: A systematic review of the literature. Stroke 2008; 39: 1911–19.


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Carotid artery disease in older people: clinical features and management

  • A Ross Naylor (a1)


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