Introduction:
Rantner: Dear listeners, welcome to a new episode of ‘Vessels in Focus – Advances in Vascular Surgery and Vascular Medicine’. My name is Barbara Rantner. I am a vascular surgeon and senior consultant at the LMU Medical Centre in Munich. This podcast is designed to offer you, dear listeners, a platform to delve deeply into the topics that shape and advance our field. Together with our guests, we will examine the latest developments in surgical, endovascular and preventive vascular medicine and discuss current – and undoubtedly controversial – topics from the worlds of science, teaching, clinical practice and the clinic. True to our motto: “We take vascular thinking further”. Today, we want to address an important question that is increasingly occupying us in vascular medicine. What role does ageing play in decision-making regarding invasive therapies? What significance does age have, and must it have, in the risk-benefit assessment for operations and interventions? We wish to discuss this topic using the example of patients with carotid stenosis, who traditionally present in our clinical practice with an average age of over 70. And I am particularly delighted to welcome my colleague and decision-maker here from the LMU Medical Centre, Prof. Dr Lars Kellert. He is Head of the Stroke Unit here at the LMU in Großhadern, a neurologist and a recognised stroke expert.
Middle section
Rantner: I am delighted to welcome Prof. Lars Kellert, Head of the Stroke Unit at LMU in Munich.
Kellert: Hello Barbara, I’m delighted that we’ll be able to speak together here over the coming period, and thank you very much for the invitation.
Rantner: Lars, we’ve been working together here at the LMU Hospital for several years now – companions, brothers in arms, so to speak – in making decisions for patients with carotid stenosis. We have octogenarians, as they’re now affectionately called – that is, patients who turn up here in their 80s, as a matter of course, so to speak. And that is why, I think, patients with carotid stenosis are particularly well-suited for us to discuss age in decision-making and perhaps also explain to our listeners aspects that are relevant to us, that can be scientifically justified, and how age – or rather, the patient’s frailty, if we wish to discuss that – should be taken into account in decision-making. We’ve selected a paper from the US, so to speak, as a basis for discussion for both of us. In 2022, data from the Vascular Quality Initiative – register data from the United States – was published, in which patients over the age of 80 who were being treated for carotid stenosis were explicitly examined. Lars, could you summarise the key findings from this publication for our listeners, so we can see how many patients were included and what the results were for the different treatment groups?
Kellert: Yes, I’d be happy to. And thank you very much for introducing the topic so well – the complex topic of vascular patients and older age; it’s certainly a difficult but very important subject. The study is based on registries – that is, data from a registry or a quality registry in the USA – and patients were included between 2005 and 2020, covering a period of 15 years and involving an impressively high total of over 28,000 patients. And as Barbara has already mentioned – and this is very important – they were all aged 80 or older and were treated for carotid stenosis, either by CA, CAS or TK. It is also important to note that the patients were actually 83 years old on average, and 49.8 per cent – if I recall correctly – had symptomatic stenoses, which is exactly half. This in turn means that the other half were asymptomatic stenoses, which is quite astonishing, because it provides a great deal of data on the outcomes and complications of asymptomatic carotid stenoses in older people, where the topic is perhaps particularly relevant. And the data from this study, at least, are very, very clear. The patients who underwent surgery had by far the lowest rate of periprocedural complications; in other words, the incidence of periprocedural stroke or death was significantly lower than in the other patients.
Rantner: Lars, as you’ve already mentioned, three different treatment methods were recorded in the registry data: the classic open surgery and carotid stenting, which can now be performed in two different ways. The classic method remains the transcarotid approach, where the carotid artery is accessed via the groin, requiring the aortic arch to be traversed and accepting the risk of embolisation through this passage through the aortic arch. And it was certainly driven by this motivation that TCAR was then developed. This is, so to speak, retrograde carotid stenting, even with flow reversal, where protection against embolisation is achieved by clamping the carotid artery on one side – thereby stopping carotid perfusion – and additionally creating a retrograde flow reversal into the femoral vein, thus minimising cerebral embolisation as much as possible. Unfortunately, the procedure is currently only available to a very limited extent here in Europe, but one could of course imagine that the procedure might be gentler, particularly for older patients. The registry data show that. What’s your view on this?
Kellert: Well, the so-called TCAR has certainly been more favourable in these registry data than the transfemoral approach, precisely to spare the aorta. You’ve just illustrated that very well. Nevertheless, the carotid-TE approach is actually superior in every respect, to be honest, even to the TCAR.
Rantner: We are quite generous in setting indications for symptomatic patients. Lars, you and I keep bumping into each other on the ward rounds. We’ve recently treated patients aged almost 90 twice in a row following a stroke. How do you assess that? In your view, for which patients would one refrain from treatment despite the threat of a stroke or despite perhaps already existing disability? Or rather, when do we not hesitate to say, in the case of a 90-year-old, ‘OK, we can operate on them with a clear conscience and they will definitely benefit from it’?
Kellert: Well, it’s obviously very important to distinguish between symptomatic and asymptomatic stenoses. Here at this site, we treat both types of patients together. So we have patients with symptomatic stenosis who typically end up in our stroke unit, and we discuss their cases very urgently and believe that we should typically treat them very early on. At the very least within the first few days or a week or two at the latest, but you have to decide quickly when to treat them. And then, of course, we have patients who come via A&E or are identified incidentally with asymptomatic stenoses. We discuss these very thoroughly as well, but we certainly tend to have a little less time pressure. With symptomatic patients, the risk of recurrent stroke is so high that, in my opinion, you primarily need good reasons not to treat them. Age is actually not a good reason in itself. We know that age ultimately varies from person to person. A 70-year-old is not simply a 70-year-old, nor is an 80-year-old simply an 80-year-old; naturally, it depends on comorbidities, the patient’s general condition, and any new findings that may come to light.
It is not uncommon for us, as part of our routine stroke diagnostics – for example, during a very deep CTA scan where we see a lot of the lung – to suddenly find a round pulmonary lesion that the patient was unaware of. And then I would say it makes sense to first check whether the patient might have a malignant lung tumour that has already metastasised. And then life expectancy must be assessed quite differently than if we hadn’t found this incidental finding at all. And then one has to consider the management of the carotid artery subsequently. In the vast majority of patients, however, the management of symptomatic carotid stenosis is such a priority that it actually takes precedence over most other conditions.
Rantner: From a specifically neurological perspective – and we often discuss this critically – if patients already have dementia or if the stroke is too debilitating, the indications will naturally be viewed critically, regardless of age. But let’s briefly discuss this idea of dementia and independence again, which plays such a central role, particularly among the elderly. How do you think this needs to be taken into account?
Kellert: Dementia as a buzzword certainly does not encompass the full range of cognitive impairments that people experience in old age. This ranges from mild cognitive impairments, which are only minimally restrictive in everyday life, to the most severe need for care and practically no participation in life at all. A clear distinction must be made here. If someone has mild cognitive impairments in daily life but is mobile and manages well, no different criteria should be applied at all than to a completely healthy patient. However, if someone is already severely impaired, either pre-existing or as a result of a stroke, then I believe the indication must also be applied very, very strictly.
Rantner: We often find ourselves in somewhat controversial discussions with relatives, because they can, of course, exert pressure in one direction or another, so to speak. From a surgical perspective, one must, of course, always ask how an operation will actually be tolerated. We now operate under local anaesthesia whenever possible and have had very good experiences with our anaesthesia team. This is particularly beneficial for older patients if general anaesthesia can be avoided. On the other hand, one must always be aware that post-operative bleeding can occur, which would then necessitate general anaesthesia. This critical balance, so to speak, with patients over 80, where you give them the ‘chance’ of a successful procedure and thus rapid rehabilitation and neurological recovery, weighed against the risk of surgical complications, general anaesthesia, post-operative delirium, and so on. It has to be balanced out a bit. What’s your view on this, Lars? How are discussions on this matter conducted with relatives and, of course, with the patients themselves?
Kellert: Well, discussions with relatives and patients must definitely be conducted on an interdisciplinary basis. It’s not enough to have just the neurologist, nor just the vascular surgeon; the cardiologists need to be on board, along with the anaesthetists and radiologists, so that we can really examine the local conditions in detail. And yet, in my experience, we always end up reaching a very sensible and rational conclusion that ultimately leaves us, the patients and their relatives, completely satisfied. So I find that we’ve very rarely encountered any real dilemmas in this regard.
Rantner: As you say, an honest conversation is certainly best. Just a quick point on stenting for symptomatic patients, particularly the elderly. That’s often what patients – and perhaps their relatives too – hear from outside sources. It can be less invasive, less of a strain on the circulatory system, and doesn’t require general anaesthesia. The evidence isn’t particularly convincing, but what’s your view on this, and how do we proceed if a patient now explicitly insists on stenting?
Kellert: First and foremost, as doctors, we have a responsibility to inform patients to the best of our knowledge and belief about what we consider to be the right course of action, and this is typically based on the available evidence. The data for surgery are simply better than for CAS, particularly in older patients. There may be situations where the patient’s wishes take precedence and where one says, ‘OK, if someone absolutely insists on it, then we must discuss this with the neuroradiologists accordingly’, and this is, after all, still a procedure associated with a very low overall risk, even if it is statistically higher than that of surgery.
Rantner: As you’ve already said, symptomatic patients actually cause us less concern, particularly in older age groups, than asymptomatic patients, who, to be honest, are increasingly presenting with these diagnoses as a matter of course. As you’ve already mentioned, the criteria for revascularisation in asymptomatic patients are set very strictly. There are now criteria relating to plaque morphology, progression and silent infarcts that are to be included in the assessment of indications, and in addition, various guidelines now require a five-year life expectancy in order for revascularisation to be considered a sensible option at all. Is surgery even an option for those over 80, or do we need to take a slightly longer-term view?
Kellert: I believe this question is extremely important and by no means irrelevant; in fact, we see these patients very frequently, and we do not always have access to these additional criteria—which are also partly laid down in the guidelines, such as progression, morphology and silent ischaemia—because the patient may have an initial diagnosis of severe ACI stenosis but has otherwise always been healthy. I think it’s very difficult to withhold surgical revascularisation from a patient when we have someone in front of us who is, for the time being, healthy. Purely statistically, I’m afraid I don’t know off the top of my head what the life expectancy is, but if we have a healthy 80-year-old, I’m fairly certain that their life expectancy is already above average, and we must first assume, as far as we can judge, that life expectancy is likely to be more than five years, and in that case I wouldn’t have any major issues with advising them to undergo surgery.
The question is, of course, can we actually predict the next five years? And, of course, we cannot do that at all. We do not know what tumour diagnoses, heart failure or whatever else might arise in the next year or two; it is simply not possible to predict that with any degree of reliability. This means that at this point we can only say that the patient is currently a healthy or relatively healthy 80-year-old, and I am very confident that the data we see here provide a strong argument and a sound basis for potentially operating on these patients even in the context of asymptomatic stenosis.
Of course, we must also qualify this by saying that these are registry data and there is no control group. That means we have no control group of patients who are simply receiving conservative treatment, and it cannot be ruled out that those over 80 with asymptomatic stenosis might also fare well with best medical treatment.
Rantner: You’ve already said it: the patient is in good shape. I’m always a bit sceptical when someone tells me, ‘Yes, the patient is in great shape, we can operate on them without any problems.’ Eighty is the new sixty, and then you see the patients and of course they are already—well, the classic vascular patient is, after all, just a classic vascular patient; they’re often diabetics, especially the carotid patients—and then you say, ‘Yes, if they’re in good shape and otherwise healthy, then you’d have no concerns.’
Would it perhaps be legitimate to pay a bit more attention to the actual situation in asymptomatic patients? Normally, carotid patients are approved for surgery with unusually little scrutiny, both from our side and from the surgical side. Anaesthetists rarely raise objections. For aortic patients, for example, we do repeatedly recommend echocardiography beforehand and that blood pressure is well controlled and so on. That’s something that isn’t applied quite so strictly with carotid patients. Could this perhaps be an approach where we say, ‘OK, we’re dealing with a patient who is younger than the average 80-year-old, but perhaps we should still invest some time in clarifying the periprocedural risk beforehand’?
Kellert: Investing more time definitely makes sense. It always depends on who assesses the patient as being in good shape. When we neurologists do this, it’s probably mostly because we actually use the so-called Modified Rankin Scale for all vascular patients. That means we look at their ability to cope with daily life. In other words, it’s not enough for us if the patient sits in front of us and says, ‘Yes, everything’s fine,’ but we really do take a close look. Are they independent? Can they walk? Can they look after themselves? Or do they already have significant limitations in daily life? And these are typically based on comorbidities, which in turn may well shift the overall prognosis in a certain direction. So, of course, as you said, it makes a great deal of sense to factor in frailty or functional ability and certainly to weigh these much more heavily than age.
I mean, ‘80 is the new 60’ would be nice, but I’m not sure if that’s actually the case. I do believe there are many people who are ageing more healthily than in the past. But of course, at some point, there’s no denying that life leaves its mark, and vascular patients are typically older to middle-aged and, naturally, almost never young patients. In other words, I think it’s a combination of several different factors.
Rantner: Well, you’re only as old as your blood vessels. Yes, Lars, you can’t quite dismiss that old saying. You’ve already used the term ‘frailty’ – it’s on everyone’s lips. Now, octogenarians and frailty – they always go hand in hand, so to speak, if you have a bit of a browse through the literature. There are, of course, many frailty scores in use. You say that neurologists use the Modified Ranking Scale to assess a patient’s independent functional ability. Do you also use frailty scores, or are you really focused on these neurological scores?
Kellert: Well, in vascular neurology, the Modified Ranking Scale is the be-all and end-all; it determines which patients are still eligible for which study. It often defines the outcome of vascular studies, namely either achieving a good ranking score or, if the patient didn’t meet the pre-study inclusion criteria, returning to baseline – that is, to the value they had previously. And that is the be-all and end-all. Of course, in other neurological fields – though I won’t digress now – there are completely different scores for Parkinson’s or similar conditions compared to strokes. But that is our score. It could certainly be expanded upon or supplemented by others, however.
Rantner: Due to these increasingly strict indications for asymptomatic carotid stenosis, we have, to some extent—I wouldn’t go so far as to say out of necessity—activated other indications, and this includes cognitive performance. For a long time, it was actually hoped that revascularisation of severe carotid stenoses might also improve cognitive performance. That would, of course, be a particularly compelling argument for older patients who may already be experiencing the onset of cognitive impairments. What is your opinion on this, and what is the current evidence?
Kellert: Well, the evidence on this is not yet convincing, and there are no randomised trials that specifically address this point; instead, it’s either always a secondary endpoint or there are no prospective clinical trials. I don’t expect cognitive function to improve simply because blood flow improves. That’s a completely unphysiological view of the brain. I could imagine that a proper study would investigate whether the progressive deterioration might be halted by revascularisation, such that the patient reaches a certain status quo, compared to a control group where revascularisation is not performed and progressive deterioration may then occur. That would be a sensible or plausible concept from a neurological perspective. One cannot imagine an improvement simply because ‘more blood or better blood’ is flowing in. That is why, of course, the brain will not function any better than before.
Rantner: That’s a shame, really. Do you assess patients’ cognitive function during these vascular consultations? Do you carry out cognitive tests on those affected?
Kellert: Yes, only if there are indications that patients are affected; then tests are carried out. For example, the MOCA, a very simple test used to detect signs of dementia. We do things like that regularly. Otherwise, of course, we also carry out a great many quality-of-life assessments, or PROMs. That’s actually what’s really important: how satisfied and how happy patients are in their everyday lives. In some cases, that’s almost far more important than the objective assessment.
Rantner: That leads us nicely into the summary we’d like to give our listeners once more. My motto for carotid revascularisation is always that we want to prevent strokes and we want to preserve patients’ independence and autonomy as much as possible, perhaps even improve it if they can then recover better from a stroke. Lars, are there any limitations for symptomatic patients? Yes, no, and if so, what are they? Just to summarise again.
Kellert: The vast majority of patients certainly benefit from revascularisation of a symptomatic stenosis. There are some exceptions – perhaps not uncommon exceptions – such as patients who have suffered very severe strokes. Firstly, there is concern about reperfusion injury if surgery is performed too early, meaning massive bleeding in the area. These are the patients with whom one must be very cautious. Secondly, because they may also have a severe neurological deficit. I think it is justified to wait a certain amount of time to see how the recovery progresses.
And then there is another group of patients where we believe, due to pre-existing comorbidities such as severe heart failure, diabetes or newly discovered tumours, that they may have a very, very reduced quality of life. In such cases, too, one might refrain from revascularisation for symptomatic carotid stenosis. But for the vast, vast majority of patients, one can only argue strongly in favour of this being the measure to prevent a recurrent stroke.
Rantner: It must also be said that it is certainly not pleasant for an 85-year-old to face the prospect of spending the last years of his life in a care home, requiring full-time care. Of course, it’s no better for a 70-year-old either, but the argument, as you put it, is particularly relevant for symptomatic patients, and in such cases age should really take a back seat.
We’ve also become more tolerant from a surgical perspective in the meantime. I mean, at the start it was like, okay, an 87-year-old patient – naturally, as a surgeon, your first thought is whether you’re willing to take that risk. But when it comes to weighing up the risks and benefits, I’m completely with you, and the data backs that up too. Open surgery in particular can be performed safely and effectively on patients and should therefore definitely be offered if it is in everyone’s best interests and, above all, in line with the patient’s wishes.
Kellert: The data suggests that. But I’m also glad – even though we’re so driven by data and studies – that our personal experiences have really always been very positive. That’s reassuring too.
Rantner: With asymptomatic patients, however, I must say I’m personally a bit more cautious; I run a carotid clinic myself, where we’re seeing more and more of these older patients. You say that if the neurologist has seen them, the indication is naturally backed up twice over. But what would your limitations be in such cases, where one says, ‘OK, let’s keep this under observation’, and the asymptomatic stenosis is actually managed more conservatively due to the patient’s age or general condition?
Kellert: A moderate degree of stenosis, I think, is crystal clear; it’s typically out of the question. It’s only from 70 per cent onwards that we’d say things get interesting. If we have patients whom we’ve possibly been following up on an outpatient basis for years, who have consistently stable findings, who are very compliant with medication and are taking the right drugs, then I see no reason to suddenly recommend surgical intervention when the degree of stenosis has remained constant for years. These are certainly patients who can be monitored further. Patients who are rapidly progressive or who suddenly present with a very severe degree of stenosis, and who may also have co-morbidities such as contralateral stenosis or contralateral occlusion, are certainly high-risk candidates who, even in the case of asymptomatic stenosis, might need to be assessed a little more strictly overall.
Rantner: Exclusion criteria – everything you’ve already mentioned regarding symptomatic cases, of course: significant heart failure, tumours, and other factors that will obviously affect life expectancy.
Kellert: Yes, certainly.
Rantner: Yes, it was fascinating and lovely to discuss these findings and the topic with you, Lars. Thank you very much again for taking the time to share this with our listeners. I hope they were able to take away some valuable insights from this episode. Lars, do you have any final words you’d like to share with our listeners?
Kellert: First of all, thank you very much to you too, Barbara, for a very entertaining 20 minutes or so. No, I think the fundamental point is that there is always individual advice for patients. That’s definitely a better approach than treating everyone the same. And I think that’s good news for all of us. Age in itself doesn’t mean that you should be excluded from valuable treatments.
Rantner: Well then, thank you once again for your attention. If you have any questions or feedback – we’re always interested in your views – please feel free to write to us. The email address is podcasts@medizinkommunikation.org, and we always save all the information and sources for the episode in the show notes, where you can also read the paper we discussed today. Otherwise, I’m already looking forward to the next episode. Until then, I wish you all the best. Stay curious and see you soon.
