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Carotid Artery Stenting: Still Not as Cost-Effective as Carotid Endarterectomy, but the Contest Continues Kosmas I. Paraskevas, MD1; Wesley S. Moore, MD2; and Frank J. Veith, MD3 Department of Vascular Surgery, Larissa University Hospital, Larissa, Greece. 2UCLA Medical Center, Los Angeles, California, USA. 3Division of Vascular Surgery, New York University Langone Medical Center, New York, New York, and Division of Vascular Surgery, The Cleveland Clinic, Cleveland, Ohio, USA. 1

After comparing the cost-effectiveness of carotid artery stenting (CAS) vs. carotid endarterectomy (CEA), Donovan et al.1 in this issue of the JEVT concluded that CAS is more costly than CEA and cannot be considered cost-effective for most carotid patients. Although hospital reimbursement was 16% highe r for CA S c ompa red with C EA ($12,0006$7372 vs. $10,1606$6840, respectively; p¼0.02), the net income per procedure for the hospital was 29% lower for CAS vs. CEA ($2603 vs. $3487, respectively).1 The reason for this was the almost 50% higher cost of CAS material ($9396 vs. $6673 for CEA).1 The cost-effectiveness analysis of CAS vs. CEA by Donovan et al.1 reaches the same conclusion as most similar cost-effectiveness analyses published to date, i.e., that CAS is associated with considerably higher costs compared with CEA.2–9 The main reason for the difference in cost between CAS and CEA is the charges directly associated with the procedure, namely, the expensive endovascular equipment and instruments.2–9 In 2011, a similar cost-effectiveness analysis calculated that the mean total hospital charges for each CAS procedure during the period 2005 to 2007 averaged $12,000 to $13,500 more than each CEA.7 During these 3 years, a

total of 404,256 carotid interventions were performed in the US [358,058 (88.6%) CEAs and 46,198 (11.4%) CAS].7 The 2011 American College of Cardiology/American Heart Association (ACC/AHA) Guideline recommended CAS as an alternative to CEA for symptomatic carotid stenosis (Class I; Level of Evidence B).10 Based on this recommendation,10 we previously demonstrated that if the percentages of CEA and CAS procedures performed during these 3 years had been the same (i.e., 50% CAS and 50% CEA), this would translate into an additional cost of ~$2,000,000,000.11 However, based on the cost-effectiveness analysis performed by Donovan et al.,1 it appears that the difference in cost between CAS and CEA has decreased since the 2011 cost-effectiveness analysis7 and will hopefully decrease even more in the future. One way to improve the cost-effectiveness of CAS may be by centralizing CAS procedures. Experienced CAS interventionists in high-volume centers of CAS excellence have lower complication rates than the average endovascular interventionalist.5,12,13 For instance, in the Pro-CAS registry, the risk of stroke after CAS decreased with center experience (5.9% for the first 50 procedures vs. 3.0% for .150 interventions; odds ratio 1.77, 95% confidence interval 1.1 to 2.8, p¼0.017).13

Invited commentaries published in the Journal of Endovascular Therapy reflect the opinions of the author(s) and do not necessarily represent the views of the Journal or the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS. The authors declare no association with any individual, company, or organization having a vested interest in the subject matter/products mentioned in this article. Corresponding author: Kosmas I. Paraskevas, MD, Department of Vascular Surgery, Larissa University Hospital, Mezourlo 41100, Larissa, Greece. E-mail: [email protected] Q 2014 by the INTERNATIONAL SOCIETY

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A policy of CAS centralization leading to lower complication rates will also translate into a reduction of overall CAS costs. Furthermore, in centers of CAS excellence, CAS may be associated with shorter lengths of hospital and intensive care unit stay, and thus similar overall costs compared with CEA.14 Even same-day discharge has been described for specific CAS patients,15 thus lowering considerably the costs associated with the hospital stay. Patient selection is another way to improve CAS cost-effectiveness. CAS may be a reasonable alternative for patients at increased perioperative risk for CEA.8,16 As stenting is a less invasive procedure compared with surgery, in patients at high risk for CEA, CAS may be associated with lower complication rates (e.g., cranial nerve palsy, myocardial infarction, hemorrhage, and the complications of anesthesia), shorter intensive care unit and hospital stays, and therefore similar14 (or even lower15) overall costs compared with CEA. At present, CAS is more costly and less cost-effective than CEA,1 but it seems that the economic gap between the two procedures is now narrower than what it was a few years ago.7 With better patient selection,8,16 centralization of CAS procedures,14,15 and improvements in CAS equipment and expertise, the cost-effectiveness of CAS is expected to improve. CAS may then become as costeffective as CEA, or even more cost-effective in specific patients at high risk of complications with CEA. Currently, however, CAS costs insurance and the government more and results in the hospitals receiving less than CEA.

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ment of carotid artery stenosis. J Am Coll Surg. 2007;205:413–419. McPhee JT, Schanzer A, Messina LM, et al. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg. 2008; 48:1442–1450. Janssen MP, de Borst GJ, Mali WP, et al. Carotid stenting versus carotid endarterectomy: evidence basis and cost implications. Eur J Vasc Endovasc Surg. 2008;36:258–264. Young KC, Holloway RG, Burgin WS, et al. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis. 2010;19:404–409. Eslami MH, McPhee JT, Simons JP, et al. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg. 2011;53:307– 315. Mahoney EM, Greenberg D, Lavelle TA, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: results from the SAPPHIRE trial. Catheter Cardiovasc Interv. 2011;77: 463–472. Sternbergh WC 3rd, Crenshaw GD, Bazan HA, et al. Carotid endarterectomy is more costeffective than carotid artery stenting. J Vasc Surg. 2012;55:1623–1628. Writing Committee Members, Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/ AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/ SNIS/ SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: A Report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Stroke. 2011;42:e464–540. Paraskevas KI, Moore WS, Veith FJ. Cost implications of more widespread carotid artery stenting consistent with the American College of Cardiology/American Heart Association guideline. J Vasc Surg. 2012;55:585–587.

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12. Vogel TR, Dombrovskiy VY, Haser PB, et al. Carotid artery stenting: impact of practitioner specialty and volume on outcomes and resource utilization. J Vasc Surg. 2009;49:1166– 1171. 13. Theiss W, Hermanek P, Mathias K, et al; German Society of Angiology/Vascular Medicine; German Society of Radiology. Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the ProCAS data. Stroke. 2008;39:2325–2330.

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14. Setacci F, de Donato G, Chisci E, et al. Economic impact of endarterectomy vs carotid artery stenting: a one year, single center study. EuroIntervention. 2007;3:340–344. 15. Gray WA, White HJ Jr, Barrett DM, et al. Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies. Stroke. 2002;33:1063–1070. 16. Sadek M, Hynecek RL, Sambol EB, et al. Carotid angioplasty and stenting, success relies on appropriate patient selection. J Vasc Surg. 2008;47:946–951.

Commentary: carotid artery stenting: still not as cost-effective as carotid endarterectomy, but the contest continues.

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