Carotid endarterectomy is more cost-effective than carotid artery stenting

Abstract

Objective: Cost-effectiveness has become an important end point in comparing therapies that may be considered to have clinical equipoise. While controversial, some feel that recent multicenter randomized controlled trials have codified clinical equipoise between carotid endarterectomy (CEA) and carotid artery stenting (CAS).

Methods: A retrospective analysis of hospital cost and 30-day clinical outcomes was performed on patients undergoing CEA and CAS between January 1, 2008 and September 30, 2010 at a single tertiary referral institution. Cost, not charges, of the index hospitalization was divided into supply, labor, facility, and miscellaneous categories. All costs were normalized to 2010 values.

Results: A total of 306 patients underwent either CEA (n = 174) or CAS (n = 132). Mean hospital cost for CAS was $9426 ± $5776 while CEA cost was $6734 ± $3935 (P < .0001). This cost differential was driven by the significantly higher direct supply costs for CAS ($5634) vs CEA ($1967) (P ≤ .0001). The higher costs for CAS were seen consistently in symptomatic, asymptomatic, elective, and urgent subgroups. Patients undergoing CAS who were enrolled in a trial or registry (53.8%) incurred significantly less cost ($7779 ± $3525) compared to those who were not ($11,279 ± $7114; P = .0004). Patients undergoing CEA trended toward a higher prevalence of being symptomatic (44.8%) compared to CAS (34.0%; P = .058). Age was not significantly different between patients undergoing CEA and CAS (70.2 vs 72.0, respectively; P = .36). Coronary artery disease was more common in patients undergoing CAS (60.3% vs 39%; P = .0001). The prevalence of chronic obstructive pulmonary disease, renal failure, hypertension, and diabetes was not significantly different between cohorts. Thirty-day combined stroke/death/myocardial infarction rate was 2.3% (4 of 174) in the CEA group and 3.8% (5 of 132) in the CAS group, P = .5. Overall length of stay (LOS) was 2.1 days in both groups (P = .9). LOS was higher for urgent interventions (7.3-7.5 days) and symptomatic status (2.9-3.5 days) when compared to patients treated electively (1.3-1.4 days).

Conclusions: Treatment of carotid disease with CAS was 40% more costly than CEA and did not provide better clinical outcomes or a reduction in LOS. These trends were consistent in symptomatic, asymptomatic, urgent, and elective subgroups At present, CAS cannot be considered a cost-effective treatment for carotid disease.