• Andrew A Fanous, Patrick K Jowdy, Simon Morr, Kunal Vakharia, Hussain Shallwani, Katalin Lorincz, L Nelson Hopkins, Jason M Davies, Kenneth V Snyder, Adnan H Siddiqui, and Elad I Levy.
• Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York, USA.
• World Neurosurg. 2019 Aug 1; 128: e513-e521.

BackgroundVarious studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy.MethodsA retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (<80 years).ResultsThe study included 447 patients: 335 patients (75%) <80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P < 0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P < 0.01, respectively), higher percentage of tortuous carotid vessels (P < 0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02).ConclusionsComplex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.Copyright © 2019 Elsevier Inc. All rights reserved.

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