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Objective: Recent studies have demonstrated that transcarotid artery revascularization (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR, and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR with CEA for carotid artery stenosis., Methods: We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness., Results: For symptomatic patients, CEA cost $7821 for 2.85 QALYs, whereas TCAR cost $19154 for 2.92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm. Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR, and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost-effective in 49% of iterations., Conclusions: This study found that, although 5-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at 6 years of follow-up., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil., Methods: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases., Results: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008)., Conclusions: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS., (Copyright © 2021. Published by Elsevier Inc.)

Background: The purpose of this study is to determinate the cost-effectiveness of carotid endarterectomy (CEA) versus transfemoral stenting (TFS) and transcervical stenting (TCS) in a short- and long-term basis in symptomatic and asymptomatic patients., Methods: From January 2003 to December 2014, patients from the vascular department, with symptomatic or asymptomatic carotid stenosis, who were clinically and anatomically suitable for TFS, TCS, or CEA, were included. Prospective cost data for each individual procedure and complication during follow-up were obtained from the diagnosis-related group. The quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios were estimated. Analysis of data was by treatment received. All statistical tests were two-sided. The significance level was 5%., Results: A total of 349 patients were enrolled: 61 for CEA (17.5%), 159 for TFS (45.5%), and 129 for TCS (37%). A total of 220 (63%) patients were symptomatic and 129 (37%) were asymptomatic. The median procedural cost and overall cost were lower on CEA (5499€ and 5595€, respectively). However, QALYs, for symptomatic patients, were better on TCS (7.3), whereas for asymptomatic patients, QALYs were better on CEA (9.6). Cost-effectiveness for symptomatic patients was better with TCS (803€/QALY), and for asymptomatic patients, it was with CEA (654€/QALY)., Conclusions: TFS and TCS were associated with clinical outcomes equivalent to CEA on both symptomatic and asymptomatic patients. Cost-effectiveness ratios for symptomatic patients were better on TCS, whereas the CEA showed the best results in asymptomatic patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There is a growing interest in providing high quality and low-cost care to Americans. A pursuit exists to measure not only how well hospitals are performing but also at what cost. We examined the variation in costs associated with carotid endarterectomy (CEA), to determine which components contribute to the variation and what drives increased payments., Materials and Methods: Patients undergoing CEA between 2009 and 2012 were identified in the Medicare provider and analysis review database. Hospital quintiles of cost were generated and variation examined. Multivariable logistic regression was performed to identify independent predictors of high-payment hospitals for both asymptomatic and symptomatic patients undergoing CEA., Results: A total of 264,018 CEAs were performed between 2009 and 2012; 250,317 were performed in asymptomatic patients in 2302 hospitals and 13,701 in symptomatic patients in 1851 hospitals. Higher payment hospitals had a higher percentage of nonwhite patients and comorbidity burden. The largest contributors to variation in overall payments were diagnosis-related groups, postdischarge, and readmission payments. After accounting for clustering at the hospital level, independent predictors of high-payment hospitals for all patients were postoperative stroke, length of stay, and readmission ,whereas in the symptomatic group, additional drivers included yearly volume and serious complications., Conclusions: CEA Medicare payments vary nationwide with diagnosis-related group, readmission, and postdischarge payments being the largest contributors to overall payment variation. In addition, stroke, length of stay, and readmission were the only independent predictors of high payment for all patients undergoing CEA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective/background: The cost-effectiveness of screening depends on the cost of screening, prevalence of asymptomatic carotid artery stenosis (ACAS), and the potential effect of medical intervention in reducing the risk of stroke. The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective., Methods: The clinical effect and cost-effectiveness of ultrasound screening for ACAS with subsequent initiation of preventive therapy versus not screening was assessed in a Markov model with a lifetime perspective. Key parameters, including stroke risk, all cause mortality, and costs, were based on contemporary published data, population statistics, and data from an ongoing screening program in Uppsala county (population 300,000), Sweden. Prevalence of ACAS (2%) and the rate of best medical treatment (BMT; 40%) were based on data from a male Swedish population recently screened for ACAS. The required stroke risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), and number needed to screen (NNS) were calculated., Results: Screening was cost-effective at an ICER of €5744 per incremental quality adjusted life year (QALY) gained. ARR was 135 per 100,000 screened, NNS was 741, and QALYs gained were 6700 per 100,000 invited. At a willingness to pay (WTP) threshold of €50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency., Conclusion: A moderate (22%) reduction in the risk of stroke was required for an ACAS screening strategy to be cost-effective at a WTP of €50,000/QALY. Targeting populations with a higher prevalence of ACAS could further improve cost-efficiency., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The U.S. Centers for Medicare and Medicaid Services (CMS) has defined a set of high-risk criteria to help define patients who are appropriate for carotid artery stenting (CAS), but these criteria have never been validated. We aimed to validate the CMS high-risk criteria in a nationally representative cohort of patients undergoing CAS and carotid endarterectomy (CEA)., Methods: All patients undergoing CAS (with embolic protection) or CEA in the Vascular Quality Initiative (VQI) database (2013-2016) were included. Patients were stratified as being at normal risk (Nr) or high risk (Hr) for undergoing CEA on the basis of CMS criteria. Thirty-day and 2-year stroke outcomes were compared for CAS vs CEA in both the Nr and Hr groups using 1:1 coarsened exact matching and multivariable Cox proportional hazards modeling., Results: A total of 51,942 patients (CAS, 7030; CEA, 44,912) underwent carotid revascularization during the study period. Thirty-day (Nr, 1.7% vs 1.0%; Hr, 2.5% vs 1.4%) and 2-year (Nr, 1.9% vs 1.0%; Hr, 2.4% vs 1.3%) stroke occurred more frequently after CAS vs CEA on crude analysis (P < .001). After matching 2920 pairs of patients on 18 preoperative variables, the risk of 30-day and 2-year stroke remained higher after CAS in the Hr group (30-day risk: hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.26-2.85; 2-year risk: HR, 1.65; 95% CI, 1.05-2.60) but was similar for CAS vs CEA in the Nr group (30-day risk: HR, 0.97; 95% CI, 0.48-1.95; 2-year risk: HR, 1.49; 95% CI, 0.76-2.90)., Conclusions: These data suggest that the utility of CAS in Nr patients may be underappreciated, whereas the potential benefit of CAS in Hr patients may be overestimated. Re-evaluation of the criteria for identifying patients at high risk for CEA and the national guidelines on the indications for CAS is strongly indicated., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Asymptomatic internal carotid artery occlusion (CO) presents a clinical dilemma, and presently, the natural history, stroke risk, and optimal management remain ill defined. This study compared outcomes, including neurovascular events (NVEs) and health care costs, between patients with CO and patients with asymptomatic carotid artery stenosis (CS)., Methods: A prospectively maintained database was queried to identify patients with CO and CS with at least >50% carotid stenosis by duplex. We identified and reviewed 622 consecutive patients with asymptomatic carotid artery disease at one academic medical center between 2011 and 2013. Patients with CO (n = 97) were identified and propensity matched by age and gender in a 1:2 ratio with CS patients (n = 194) for further analyses. Univariate and multivariate models were used to analyze baseline characteristics, clinical variables, and 1-year follow-up data from the date of diagnosis. Multivariate analysis was performed by multiple linear regression modeling. Institutional Review Board approval was obtained., Results: Follow-up data were available for 99% of matched patients. CO patients were younger (72 vs 75 years; P < .01) and more likely male (67% vs 53%; P = .01) compared with CS patients. After propensity matching, baseline characteristics were similar between groups, with a trend toward higher use of statin therapy among patients with CO. Antiplatelet therapy was used in 79% of patients with CS and in 74% of patients with CO (P = .45). The rate of NVE among CO patients was higher than among CS patients at 1 year of follow-up (14% vs 7%; P = .03). Among those with NVE, neither antiplatelet therapy (64% vs 77%; P = .49) nor statin therapy (86% vs 77%; P = .58) appeared to have a significant effect. Health care costs ($14,361 vs $12,142; P = .44) and hospital admission rate (63% vs 71%; P = .18) were similar between groups. Not surprisingly, the rate of vascular procedures was higher in the CS group (55% vs 27%; P = .04)., Conclusions: Patients with asymptomatic CO experience more NVEs compared with similar patients with moderately severe CS. Further study of preventative strategies, including intensity of medical therapy, is warranted., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We aimed to identify factors associated with cost of carotid artery stenting (CAS)., Methods: Patient and hospital characteristics affecting cost of admission for CAS were identified using the Vizient national database of hospital-reported outcomes. Patients who underwent CAS for either asymptomatic or symptomatic carotid stenosis were identified using surgical Medicare Severity-Diagnosis Related Groups and appropriate International Classification of Diseases, Ninth Revision and Tenth Revision codes., Results: There were 166 hospitals that reported outcomes from 7369 inpatient admissions for CAS. Each institution reported a mean value for cost related to patient care per admission for CAS; the average cost across all reporting institutions was $12,834.14 (standard error of the mean [SEM], 492.88). Institutions in the lowest 25th percentile with respect to frequency of intensive care unit admission after CAS had lower cost of admission than institutions above the 75th percentile ($10,971.30 [SEM, 460.67] vs $14,992.90 [964.29]; P = .002), without any differences in incidence of stroke during admission (2.2% [SEM, 0.3] vs 2.0% [0.4]; P = .877) or 30-day readmission (1.9% [SEM, 0.4] vs 2.5 [0.6]; P = .329). Admissions for patients with symptomatic stenosis were more expensive than those with asymptomatic stenosis ($20,462.10 [SEM, 819.93] vs $11,285.20 [347.11]; P < .001). Obesity was also associated with greater costs of admission ($14,176.20 [SEM, 597.13] vs $12,287.10 [395.73]; P < .001)., Conclusions: Admission to an intensive care unit, symptomatic stenosis, and obesity were associated with increased costs in patients undergoing CAS. These data may aid in identifying opportunities to improve the cost-effectiveness of this procedure., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness., Methods: A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA., Results: Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835., Conclusions: This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment., Objective: To explore evidence for provider-induced demand in the management of carotid artery stenosis., Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016., Main Outcomes and Measures: The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand., Results: Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001)., Conclusions and Relevance: Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

Objective: Despite multiple landmark clinical trials, little data exists on real-world cost of carotid artery stenting (CAS) and carotid endarterectomy (CEA) to the United States healthcare system. We aim to study differences in actual hospitalization cost between patients who underwent CAS vs CEA in a nationally representative database., Methods: We studied hospital discharge and billing records of all patients, in the Premier Perspective Database, who underwent CEA or CAS between the third quarter of 2009 and the first quarter of 2015. Nearest-neighbor 1:1 propensity score matching was performed, to account for differences in patient and hospital characteristics as well as clinical comorbidities of patients who underwent both procedures, for both symptomatic and asymptomatic cohorts using 32 variables. Pearson χ 2 , Student t-test, and nonparametric K-sample equality-of-medians tests were used to analyze the data, as appropriate. The primary outcome was total in-hospital cost, including fixed (administrative, capital and utilities) and variable costs (labor and supply). Cost data were presented as medians, inflation-adjusted for 2015 U.S. dollar and rounded to the nearest dollar., Results: A total of 115,548 procedures were identified. The mean age was 71 and 69 years; 58% and 57% were male patients; and 81% and 77% were white among asymptomatic and symptomatic patients, respectively. After propensity score matching, 25,812 asymptomatic (12,906 CEA and 12,906 CAS) and 3864 symptomatic (1932 CEA and 1932 CAS) patients were included. Total hospitalization cost per CAS was 40% ($11,814 vs $8378; P < .001) and 37% ($19,426 vs $14,190; P < .001) higher than CEA among asymptomatic and symptomatic patients, respectively. Patients who underwent CAS incurred significantly higher total hospitalization cost despite stratifying by type of cost (fixed and variable), U.S. census regions and symptomatic status. Moreover, asymptomatic patients who underwent CAS performed by any surgical specialty incurred an average of $2717 to $4918 higher total hospitalization cost compared with patients who underwent CEA (all P < 001). Among symptomatic patients, those who underwent CAS performed by vascular, cardiac, and neurologic surgeons, incurred $2108 ($16,114 vs $14,006; P = .006), $7055 ($17,351 vs $10,296; P = .023) and $6479 ($27,290 vs $20,811; P = .002) higher total hospitalization cost compared with patients who underwent CEA, respectively., Conclusions: The total hospitalization cost incurred by patients who underwent CAS was significantly higher than for those who underwent CEA, despite matching cohort based on patient and hospital characteristics, and stratifying by symptomatic status, type of cost, hospital region, and surgeon specialty. Our findings could provide additional important information giving the ongoing controversy regarding the appropriate indication for CAS., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR)., Methods: Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country., Results: Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7)., Conclusions: Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Medical care in the United States has evolved into a more cost-conscious value-based health care system that necessitates a comparison of costs when there are alternative interventions considered to be acceptable in the treatment of a disease. This study compares the cost differences between regional anesthesia (RA) and general anesthesia (GA) for carotid endarterectomy (CEA)., Methods: Data from 346 consecutive patients who underwent CEA between January 2012 and September 2014 were retrospectively reviewed for the type of anesthesia used, outcomes data, and cost variables. Overall hospital day costs were compared between RA and GA. Medians and interquartile ranges were compared using Wilcoxon-Mann-Whitney test. A P < 0.05 was considered statistically significant using 2-sided tests., Results: Median overall costs for GA were significantly higher than median costs for RA (medians [with interquartile ranges], $10,140 [$7,158-$12,658] versus $7,122 [$5,072-$8,511], P < 0.001). Median total operative time for GA was significantly longer than median time for RA (168 [144-188] versus 134 [115-147] min, P < 0.001). Median in-hospital length of stay (LOS) for GA was significantly longer compared with RA (2.0 vs 1.2 days, P < 0.001). Patients who received GA were also more likely to be admitted to the intensive care unit., Conclusions: Decreased cost, operating room expenses, postoperative resources, and overall LOS were observed for individuals who underwent RA for CEA as compared with GA. In summary, RA is more cost-effective and should be the optimal choice when clinically appropriate., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay., Methods: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day., Results: Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05)., Conclusions: Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are complementary techniques for management of patients with carotid artery stenosis. This study investigates the impact of chronic kidney disease (CKD) and age on outcomes after carotid artery revascularization., Methods/materials: National Inpatient Sample was surveyed for CAS and CEA among stage 3 and 4 CKD and stage 5/end stage renal disease (ESRD) patients from 2004 to 2012. Primary endpoint was in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) stratified by kidney function and age. Regression analysis and propensity score matching were utilized., Results: There were 3299 patients that underwent CEA and 652 underwent CAS with stage 3 and 4 CKD. Whereas, 1630 patients underwent CEA and 511 patients underwent CAS with stage 5 CKD/ESRD. Patients undergoing CAS had more in-hospital MACCE. Coronary artery disease (OR1.35, 95%CI:1.07-1.70) and CAS (OR1.35, 95%CI:1.02-1.77) were independently associated with MACCE for stage 3 and 4 CKD patients. For the stage 5 CKD/ESRD cohort, CAS (OR1.75, 95%CI:1.29-2.37) was independently associated with MACCE. Stratifying by age, showed no difference in event rates except for higher MACCE among patients <60years old with stage 5 CKD/ESRD undergoing CAS (p<0.001). Propensity score matching showed that treatment type had no significant effect on MACCE rates., Conclusions: Among CKD cohorts studied nationally, in-hospital MACCE were higher for patients that underwent CAS. Overall, age group analyses showed that there was no difference in MACCE rates between CAS and CEA. Although CAS was independently associated with MACCE, propensity score matching showed no risk difference of MACCE between CAS and CEA for either CKD cohort., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Carotid endarterectomy (CEA) for asymptomatic patients with limited life expectancy may not be beneficial or cost-effective. The purpose of this study was to examine relationships among survival, outcomes, and costs within 2 years following CEA among asymptomatic patients., Methods: Prospectively collected data from 3097 patients undergoing CEA for asymptomatic disease from Vascular Quality Initiative VQI registry were linked to Medicare. Models were used to identify predictors of 2-year mortality following CEA. Patients were classified as low, medium, or high risk of death based on this model. Next, we examined costs related to cerebrovascular care, occurrence of stroke, rehospitalization, and reintervention within 2 years following CEA across risk strata., Results: Overall, 2-year mortality was 6.7%. Age, diabetes, smoking, congestive heart failure (CHF), chronic obstructive pulmonary disease, renal insufficiency, absence of statin use, and contralateral internal carotid artery (ICA) stenosis were independently associated with a higher risk of death following CEA. In-hospital costs averaged $7500 among patients defined as low risk for death, and exceeded $10,800 among high risk patients. Although long-term costs related to cerebrovascular disease were 2 times higher in patients deemed high risk for death compared with low risk patents ($17,800 vs. $8800, P = 0.001), high risk of death was not independently associated with a high probability of high cost. Predictors of high cost at 2 years were severe contralateral ICA stenosis, dialysis dependence, and American Society for Anesthesia Class 4. Both statin use and CHF were protective of high cost., Conclusions: Greater than 90% of patients undergoing CEA live long enough to realize the benefits of their procedure. Moreover, the long-term costs are supported by the effectiveness of this procedure at all levels of patient risk., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The International Carotid Stenting Study was a multicenter randomized trial in which patients with symptomatic carotid artery stenosis were randomly allocated to treatment by carotid stenting or endarterectomy. Economic evidence comparing these treatments is limited and inconsistent., Aims: We compared the cost-effectiveness of stenting versus endarterectomy using International Carotid Stenting Study data., Methods: We performed a cost-utility analysis estimating mean costs and quality-adjusted life years per patient for both treatments over a five-year time horizon based on resource use data and utility values collected in the trial. Costs of managing stroke events were estimated using individual patient data from a UK population-based study (Oxford Vascular Study)., Results: Mean costs per patient (95% CI) were US$10,477 ($9669 to $11,285) in the stenting group (N = 853) and $9669 ($8835 to $10,504) in the endarterectomy group (N = 857). There were no differences in mean quality-adjusted life years per patient (3.247 (3.160 to 3.333) and 3.228 (3.150 to 3.306), respectively). There were no differences in adjusted costs between groups (mean incremental costs for stenting versus endarterectomy $736 (95% CI -$353 to $1826)) or adjusted outcomes (mean quality-adjusted life years gained -0.010 (95% CI -0.117 to 0.097)). The incremental net monetary benefit for stenting versus endarterectomy was not significantly different from zero at the maximum willingness to pay for a quality-adjusted life year commonly used in the UK. Sensitivity analyses showed little uncertainty in these findings., Conclusions: Economic considerations should not affect whether patients with symptomatic carotid stenosis undergo stenting or endarterectomy., (© 2016 World Stroke Organization.)

Background and Objective: The cost-effectiveness of clinical interventions is often assessed using current care as the comparator, with national guidelines as a proxy. However, this comparison is inadequate when clinical practice differs from guidelines, or when clinical practice differs between hospitals. We examined the degree of variation in the way patients with a recent transient ischemic attack (TIA) or minor ischemic stroke are assessed and used the results to illustrate the importance of investigating possible clinical practice variation, and the need to perform hospital-level cost-effectiveness analyses (CEAs) when variation exists., Methods: Semi-structured interviews were conducted with 16 vascular neurologists in hospitals throughout the Netherlands. Questions were asked about the use of initial and confirmatory diagnostic imaging tests to assess carotid stenosis in patients with a recent TIA or minor ischemic stroke, criteria to perform confirmatory tests, and criteria for treatment. We also performed hospital-level CEAs to illustrate the consequences of the observed diagnostic strategies in which the diagnostic test costs, sensitivity and specified were varied according to the local hospital conditions., Results: 56 % (9/16) of the emergency units and 63 % (10/16) of the outpatient clinics use the initial and confirmatory diagnostic tests to assess carotid stenosis in accordance with the national guidelines. Of the hospitals studied, only one uses the recommended criteria for use of a confirmatory test, 38 % (6/16) follow the guidelines for treatment. The most cost-effective diagnostic test strategy differs between hospitals., Conclusions: If important practice variation exists, hospital-level CEAs should be performed. These CEAs should include an assessment of the feasibility and costs of switching to a different strategy.

Background: To curb increasing volumes of diagnostic imaging and costs, reimbursement for carotid duplex ultrasound (CDU) is dependent on "appropriate" indications as documented by International Classification of Diseases (ICD) codes entered by ordering physicians. Historically, asymptomatic indications for CDU yield lower rates of abnormal results than symptomatic indications, and consensus documents agree that most asymptomatic indications for CDU are inappropriate. In our vascular laboratory, we perceived an increased rate of incorrect or inappropriate ICD codes. We therefore sought to determine if ICD codes were useful in predicting the frequency of abnormal CDU. We hypothesized that asymptomatic or nonspecific ICD codes would yield a lower rate of abnormal CDU than symptomatic codes, validating efforts to limit reimbursement in asymptomatic, low-yield groups., Material and Methods: We reviewed all outpatient CDU done in 2011 at our institution. ICD codes were recorded, and each medical record was then reviewed by a vascular surgeon to determine if the assigned ICD code appropriately reflected the clinical scenario. CDU findings categorized as abnormal (>50% stenosis) or normal (<50% stenosis) were recorded. Each individual ICD code and group 1 (asymptomatic), group 2 (nonhemispheric symptoms), group 3 (hemispheric symptoms), group 4 (preoperative cardiovascular examination), and group 5 (nonspecific) ICD codes were analyzed for correlation with CDU results., Results: Nine hundred ninety-four patients had 74 primary ICD codes listed as indications for CDU. Of assigned ICD codes, 17.4% were deemed inaccurate. Overall, 14.8% of CDU were abnormal. Of the 13 highest frequency ICD codes, only 433.10, an asymptomatic code, was associated with abnormal CDU. Four symptomatic codes were associated with normal CDU; none of the other high frequency codes were associated with CDU result. Patients in group 1 (asymptomatic) were significantly more likely to have an abnormal CDU compared to each of the other groups (P < 0.001, P < 0.001, P = 0.020, P = 0.002) and to all other groups combined (P < 0.001)., Conclusions: Asymptomatic indications by ICD codes yielded higher rates of abnormal CDU than symptomatic indications. This finding is inconsistent with clinical experience and historical data, and we suggest that inaccurate coding may play a role. Limiting reimbursement for CDU in low-yield groups is reasonable. However, reimbursement policies based on ICD coding, for example, limiting payment for asymptomatic ICD codes, may impede use of CDU in high-yield patient groups., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Several studies have reported on the role of postoperative duplex ultrasound surveillance after carotid endarterectomy (CEA) with varying results. Most of these studies had a small sample size or did not analyze cost-effectiveness., Methods: We analyzed 489 of 501 CEA patients with patch closure. All patients had immediate postoperative duplex ultrasound examination and were routinely followed up both clinically and with duplex ultrasound at regular intervals of 1 month, 6 months, 12 months, and every 12 months thereafter. A Kaplan-Meier analysis was used to estimate the rate of ≥50% and ≥80% post-CEA restenosis over time and the time frame of progression from normal to ≥50% or ≥80% restenosis. The cost of post-CEA duplex surveillance was also estimated., Results: Overall, 489 patients with a mean age of 68.5 years were analyzed. Ten of these had residual postoperative ≥50% stenosis, and 37 did not undergo a second duplex ultrasound examination and therefore were not included in the final analysis. The mean follow-up was 20.4 months (range, 1-63 months), with a mean number of duplex ultrasound examinations of 3.6 (range, 1-7). Eleven of 397 patients (2.8%) with a normal finding on immediate postoperative duplex ultrasound vs 4 of 45 (8.9%) with mild stenosis on immediate postoperative duplex ultrasound progressed to ≥50% restenosis (P = .055). Overall, 15 patients (3.1%) had ≥50% restenosis, 9 with 50% to <80% and 4 with 80% to 99% (2 of these had carotid artery stenting reintervention), and 2 had late carotid occlusion. All of these were asymptomatic, except for one who had a transient ischemic attack. The mean time to ≥50% to <80% restenosis was 14.7 months vs 19.8 months for ≥80% restenosis after the CEA. Freedom from restenosis rates were 98%, 96%, 94%, 94%, and 94% for ≥50% restenosis and 99%, 98%, 97%, 97%, and 97% for ≥80% restenosis at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. Freedom from myocardial infarction, stroke, and deaths was not significantly different between patients with and without restenosis (100%, 93%, 83%, and 83% vs 94%, 91%, 86%, and 79% at 1 year, 2 years, 3 years, and 4 years, respectively; P = .951). The estimated charge of this surveillance was 3.6 × 489 (number of CEAs) × $800 (charge for carotid duplex ultrasound), which equals $1,408,320, to detect only four patients with ≥80% to 99% restenosis who may have been potential candidates for reintervention., Conclusions: This study shows that the value of routine postoperative duplex ultrasound surveillance after CEA with patch closure may be limited, particularly if the finding on immediate postoperative duplex ultrasound is normal or shows minimal disease., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The introduction of carotid stenting has led to a rapid rise in the number of vascular specialists performing this procedure. The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) has shown that carotid stenting can be performed with an equivalent major event rate compared with carotid endarterectomy. However, there is still controversy about the appropriate training and experience required to safely perform this procedure. This observational study examined the performance of carotid stenting with regard to specialty and case volume., Methods: From 2004 to 2011, inpatients diagnosed with carotid stenosis who had a carotid stenting procedure were extracted from the Nationwide Inpatient Sample database. The cohort was separated on the basis of the provider performing the procedure (surgeon vs interventionalist), hospital location, and volume. Surgeons were defined as providers who also performed either a carotid endarterectomy or femoral-popliteal bypass during the same time interval. Primary end points analyzed included stroke, myocardial infarction, and 30-day mortality. Length of stay and hospital costs were also analyzed as secondary outcomes., Results: A total of 20,663 cases of carotid stenting were found; 15,305 (74%) cases were identified to be performed by a "surgeon," whereas 5358 (26%) were done by an "interventionalist." The majority of cases were done at hospitals in urban locations (96.51%) and designated teaching institutions (61.47%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% and 4.41%), myocardial infarction (2.10% and 2.13%), and mortality (0.84% and 1.03%) respectively. Qualitatively, volume per 10 cases was shown to decrease the risk of stroke. Adjusted multivariate analysis demonstrated no statistical significance between primary end point outcomes. However, length of stay (2.81 vs 3.08 days) and total charges ($48,087.61 and $51,718.77) were lower for procedures performed by surgeons., Conclusions: Surgeons are performing the majority of carotid stent procedures in the United States. The volume of cases performed by a provider, rather than the provider's specialty, appears to be a stronger predictor of adverse outcomes for carotid stenting. There were, however, significant cost differences between surgeons and interventionalists, which needs to be further evaluated at an institutional level., (Published by Elsevier Inc.)

Purpose: To project and compare the lifetime health benefits, health care costs, and incremental cost-effectiveness of a decision rule based on assessment of cerebrovascular reserve (CVR) compared with medical therapy and immediate revascularization in asymptomatic patients with carotid artery stenosis for prevention of stroke., Materials and Methods: The three strategies compared included immediate revascularization (carotid endarterectomy) and ongoing medical therapy (with antiplatelet, statin, and antihypertensive agents plus lifestyle modification), medical therapy-based treatment with revascularization only for patients who progressed, and use of a CVR-based decision rule for treatment in which patients with CVR impairment undergo immediate revascularization and all others receive medical therapy. A decision analytic model was developed to project lifetime quality-adjusted life years (QALYs) and costs for asymptomatic patients with carotid stenosis with 70%-89% carotid luminal narrowing at presentation. Risks of clinical events, costs, and quality-of-life values were estimated on the basis of those in published sources. The analysis was conducted from a health care system perspective, with health and cost outcomes discounted at 3%. Results Total costs per person and lifetime QALYs were lowest for the medical therapy-based strategy ($14 597, 9.848 QALYs), followed by CVR testing ($16 583, 9.934 QALYs) and immediate revascularization ($20 950, 9.940 QALYs). The incremental cost-effectiveness ratio for the CVR-based strategy compared with the medical therapy-based strategy was $23 000 per QALY and for the immediate revascularization versus the CVR-based strategy was $760 000 per QALY., Results: were sensitive to variations in model inputs for revascularization costs and complication risks and baseline stroke risk., Conclusion: CVR testing can be a cost-effective tool to identify asymptomatic patients with carotid stenosis who are most likely to benefit from revascularization., (© RSNA, 2014.)

Objective: This study compared in-hospital mortality and resource utilization among vascular surgical patients at safety net public hospitals (SNPHs) with those at nonsafety net public hospitals (nSNPHs)., Methods: The National Inpatient Sample (2003-2011) was queried to identify surgical patients with peripheral arterial disease (PAD), carotid stenosis, or nonruptured abdominal aorta aneurysm based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. The cohort was then divided into SNPH and nSNPH groups according to the definition of SNPH used by the National Association of Public Hospitals. Clinical characteristics, length of stay, in-hospital mortality, and hospital charges were compared between groups. Advanced PAD was defined as that associated with rest pain or tissue loss. Statistical methods included bivariate χ(2) tests for categoric variables, t-tests for continuous variables, and multivariable linear and logistic regression to adjust for confounding variables (in-hospital mortality)., Results: We identified 306,438 patients operated on for PAD, carotid stenosis, and abdominal aortic aneurysm. Patients at SNPHs were younger, the percentage of female and minority patients was higher, and patients had a higher Elixhauser comorbidity index (P < .001). Nonelective admissions were more common among SNPH patients who presented with more advanced PAD (P > .05) and symptomatic carotid stenosis (P < .05). Patients at SNPHs had a significantly longer length of stay, higher hospital charges, and higher in-hospital mortality (P < .05 for all variables). Crude odds of mortality at SNPHs were 1.28 higher than at nSNPHs (95% confidence interval, 1.13-1.46; P < .001), but adjusted analyses revealed no statistically significant difference between the odds of in-hospital mortality at both hospital groups., Conclusions: Patients undergoing vascular surgery at SNPHs, despite being younger, had higher comorbidities, presented more urgently with more advanced disease, and incurred higher costs than the SNPH cohort despite similar adjusted odds of in-hospital mortality. Delayed presentation and higher comorbidities are most likely related to poor access to routine and preventive health care for the SNPH patients., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated., Methods: We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention., Results: 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality., Conclusions: Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The choice of carotid artery endarterectomy (CEA) or carotid artery stenting (CAS), as surgical and interventional treatment of atherosclerotic carotid stenosis, respectively, has been controversial in decades, especially for asymptomatic patients with carotid stenosis. Age and the diameter of impaired carotid artery might be 2 important factors to decide whether CEA or CAS should be performed. Besides, contrast-enhanced ultrasound (CEUS) has been confirmed as an effective method to predict the risk of stroke by classifying the carotid plaque into 4 grades. The role of CEUS in the choice of CEA or CAS still remains unclear., Methods: A retrospective analysis of 38 patients who underwent CEA with primary closure and 36 patients who underwent CAS in our hospital from October 2008 to January 2013 is conducted. Preoperative CEUS was performed to all patients, and data were collected and analyzed. All CEAs were performed with transverse incision., Results: The hospital stay was longer for the endarterectomy group than the stenting group (15.39 versus 10.91 d, P < 0.001), with an approximately two-third reduction of hospital costs (¥23686.21 versus ¥60855.34, P < 0.001). The overall incidence of perioperative complications in the endarterectomy group was 7.9%, with no statistically significant difference in the group with internal carotid artery greater than or equal to 5 mm and in the group with internal carotid artery less than 5 mm (9.1% versus 6.3%, P = 0.75). No restenosis occurred in either of the subgroups during the follow-up. In patients older than 70 years, the perioperative complications were 0% in CEA and 10.53% in CAS (P = 0.42); the long-term restenosis was 0% in CEA and 5.26% in CAS (P = 0.67). In patients younger than 70 years, the perioperative complications were 11.5% in CEA and 23.53% in CAS (P = 0.31); the long-term restenosis was 0% in CEA and 0% in CAS (P > 0.01). For patients with grade 4 plaque in CEUS, the incidence of adverse events in the CAS group was significantly higher than that in the CEA group (7.14% versus 55.56%, P < 0.05)., Conclusions: There were no significant differences in perioperative complications or restenosis rate between the CAS group and the CEA group in this study. Neither the diameter of impaired carotid artery or age could be considered as an indication of applying CEA or CAS. However, CEUS might be used as a perioperative assessment method to decide whether CEA or CAS should be performed to different patients. The higher the grade of plaque enhancement, the higher the risk of adverse events and restenosis for CAS might occur.

Background: Carotid artery stenting (CAS) was introduced in the United States nearly a decade ago as a novel treatment of severe carotid stenosis. Voluminous and high-quality prospective data permit analysis of longitudinal trends in CAS outcomes., Methods: Outcomes from all prospective trials with the Food and Drug Administration (FDA) oversight from 2000-2011 were reviewed, as were the subset of studies using a single CAS system. All studies shared common inclusion/exclusion criteria, endpoints, independent assessment/adjudication of neurological events, and were conducted in accordance with FDA regulations. Death and stroke (DS) rates from FDA-approved studies in high-surgical-risk patients were assessed., Results: Between 2000 and 2011, two distinct periods with clustered and differentiated outcomes in CAS IDE trials were observed, separated by FDA approval and Centers for Medicare and Medicaid Services (CMS) coverage in 2004-2005. The mean 30-day DS rate in the first wave (2000-2004) of CAS trials was 5.3% (95% CI: 4.6-6.2%), and fell significantly to 2.6% (95% CI: 1.9-3.7%; P = 0.0001) in the second wave (2006-2011). This decline occurred during a simultaneous, independent 24-fold increase in monitored CAS activity. This decline in DS rates was observed in symptomatic and asymptomatic patients, alike independent of device tested., Conclusions: Declines in periprocedural DS rates in CAS appear linked to regulatory and coverage approvals leading to increased operator experience along with continued regulatory oversight, and provide insight into the introduction of other novel therapies., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: The indications for carotid revascularization are based almost exclusively on the results of carotid duplex ultrasonography. Noninvasive vascular laboratories show large variation in the diagnostic criteria used to classify degree of carotid artery stenosis. We hypothesize that variability of these diagnostic criteria causes significant variation in stenosis classification directly affecting the number of revascularizations and associated costs., Methods and Results: The diagnostic criteria to interpret carotid duplex ultrasounds were obtained from 10 New England institutions. All carotid duplex scans performed at our institution were reviewed from 2008 to 2012. Using the diagnostic criteria from each institution, the degree of stenosis that would have been reported was classified as 70% to 99% asymptomatic, 80% to 99% asymptomatic, and 50% to 99% symptomatic. We then calculated the theoretical number of carotid revascularization procedures that this cohort would be offered using each institution's diagnostic criteria and the costs of these procedures based on reimbursement rates. Among 10 614 patients who underwent 15 534 carotid duplex scans, 31 025 arteries were reviewed. Application of the 10 institutions' criteria to the patients from our institution yielded marked variation in the number classified as 70% to 99% asymptomatic (range, 186-2201), 80% to 99% asymptomatic (range, 78-426), and 50% to 99% symptomatic (range, 157-781). If revascularizations were based on these results, costs would range from $2.2 to $26 million, $0.9 to $5.0 million, and $1.9 to $9.2 million, respectively., Conclusions: Differences in diagnostic criteria to interpret carotid ultrasound result in significant variation in classification of carotid artery stenosis, likely leading to differences in the number and subsequent costs of revascularizations. This theoretical model highlights the need for standardization of carotid duplex criteria., (© 2014 American Heart Association, Inc.)

Background and Purpose: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy., Materials and Methods: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial., Results: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (-0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy., Conclusions: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

Background: Perioperative stroke is a devastating complication after cardiac surgery. In an attempt to minimize this complication, many cardiac surgeons routinely preoperatively order carotid artery duplex scans to assess for significant carotid stenosis. We hypothesize that the routine screening of preoperative cardiac surgery patients with carotid artery duplex scans detects few patients who would benefit from carotid intervention or that a significant carotid stenosis reliably predicts stroke risk after cardiac surgery., Methods: A retrospective review identified 1,499 patients who underwent cardiac surgical procedures between July 1999 and September 2010. Data collected included patient demographics, comorbidities, history of previous stroke, preoperative carotid artery duplex scan results, location of postoperative stroke, and details of carotid endarterectomy (CEA) procedures before, in conjunction with, or after cardiac surgery. Statistical methods included univariate analysis and Fisher's exact test., Results: Twenty-six perioperative strokes were identified (1.7%). In the 21 postoperative stroke patients for whom there is complete carotid artery duplex scan data, 3 patients had a hemodynamically significant lesion (>70%) and 1 patient underwent unilateral carotid CEA for bilateral disease. Postoperative strokes occurred in the anterior cerebral circulation (69.2%), posterior cerebral circulation (15.4%), or both (15.4%). Patient comorbidities, preoperative carotid artery duplex scan screening velocities, or types of cardiac surgical procedure were not predictive for stroke. Thirteen patients (0.86%) underwent CEA before, in conjunction with, or after cardiac surgery. Two of these patients had symptomatic disease, 1 of whom underwent CEA before and the other after his cardiac surgery. Of the 11 asymptomatic patients, 2 underwent CEA before, 3 concurrently, and 6 after cardiac surgery. Left main disease (≥50% stenosis), previous stroke, and peripheral vascular disease were found to be statistically significant predictors of carotid revascularization. A cost analysis of universal screening resulted in an estimated net cost of $378,918 during the study period., Conclusions: The majority of postoperative strokes after cardiac surgery are not related to extracranial carotid artery disease and they are not predicted by preoperative carotid artery duplex scan screening. Consequently, universal carotid artery duplex scan screening cannot be recommended and a selective approach should be adopted., (Published by Elsevier Inc.)

Objective: We have previously demonstrated an adverse impact of black race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS). The current study was undertaken to examine the influence of race and ethnicity on the cost of CEA and CAS., Methods: The Nationwide Inpatient Sample (2005-2009) was queried using ICD-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcome was total hospital charges. Multivariate analysis was performed using a generalized linear model adjusting for age, sex, race, comorbidities (Charlson index), high-risk status, procedure type, symptomatic status, year, insurance type, and surgeon and hospital operative volumes and characteristics., Results: Hispanic and black patients were more likely to have a symptomatic presentation, and were more likely to undergo either CEA or CAS by low-volume surgeons at low-volume hospitals (P < 0.05, all). They were also less likely to have private insurance or Medicare (P < 0.001). Overall, CEA was less expensive than CAS over the 4-y study period ($29,502 ± $104 versus $46,713 ± $409, P < 0.001). Total hospital charges after CEA were increased in both blacks ($39,562 ± $843) and Hispanics ($45,325 ± $735) compared with whites on univariate analysis ($28,403 ± $101, P < 0.001). After CAS, total hospital charges were similarly increased in both blacks ($51,770 ± $2085) and Hispanics ($63,637 ± $2766) compared with whites on univariate analysis ($45,550 ± $412, P < 0.001). On multivariable analysis, however, only Hispanic ethnicity remained independently associated with increased charges after both CEA (exponentiated coefficient 1.18; 95% CI [1.15-1.20]; P < 0.001) and CAS (exponentiated coefficient 1.17; 95% CI [1.09-1.24]; P < 0.001)., Conclusion: Hispanic ethnicity was independently associated with increased hospital charges after both CEA and CAS. The increased charges seen in black patients were explained, in part, by decreased surgeon operative volume and increased postoperative complications. Further efforts are warranted to contain costs in minorities undergoing carotid revascularization., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST)., Methods: This was a cost-utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates., Results: The ICER was £7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £20,000 and £30,000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £3254, and that for men aged 75 years or above was £71,699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective., Conclusion: In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £20,000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Carotid artery stenting (CAS) has been covered by the health insurance system in Japan since 2008. There have been few studies concerning medical costs and charges for patients who received CEA or CAS in Japan. The aim of this study was to elucidate the difference in the costs between the patients who received CEA and those who received CAS in Japan. Between 2010 and 2011, 19 patients who received CEA and 20 patients who received CAS were retrospectively reviewed. Age, sex, symptomatic/asymptomatic, emergent/scheduled, length of stay, outcome, cost for the procedure (professional fee), supply for the operation, the total medical service fee, and copayment of the patients was compared between the two treatment groups. No significant difference was detected between the two groups except for the supply of the operation and the total medical service fee (CEA:mean 1,565,580 yen vs CAS 2,758,360 yen, p=0.0001). On the other hand, no significant difference was obtained in the copayment of the patients (CEA 71,895 yen, CAS 72,458 yen). Even when limited to the scheduled cases, similar results were obtained. There is a monthly copayment limit in the health insurance system in Japan, which results in a reasonable charge for patients who received CAS, despite the fact that the rest of the fee including high costs for the supplies was paid by the company and the nation. To reduce the medical costs, Japanese have to be aware of the high costs in CAS, most of which is due to the supplies.

Unlabelled: The objective of this article is to assess the availability and validity of economic evaluations of carotid artery stenosis (CS) diagnosis and treatment., Design: Systematic review of economic evaluations of the diagnosis and treatment of CS., Methods: Systematic review of full economic evaluations published in Medline and Google Scholar up until 28 February 2012. Based on economic checklists (Evers and Philips), the identified studies were classified as high, medium, or low quality., Results: Twenty-three evaluations were identified. The study quality ranged from 26% to 84% of all achievable points (Evers). Seven studies were of high, eight of medium and eight of low quality. No comparison was made between carotid angioplasty and stenting (CAS) and best medical treatment (BMT). For subjects with severe stenosis, comparisons of carotid endarterectomy (CEA) and BMT were also missing. Three of five studies dealing with pre-operative imaging found that duplex Doppler ultrasound (US) was cost-effective compared with carotid angiogram (AG)., Conclusions: There is a huge lack of high-quality studies and of studies that confirm published results. Also, for a given study quality, the most cost-effective treatment strategy is still unknown in some cases ('CAS' vs. 'BMT', 'US combined with magnetic resonance angiography supplemented with AG' vs. 'US combined with computer tomography angiography')., (Copyright © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated similar rates of the primary composite end point between carotid artery stenting (CAS) and carotid endarterectomy (CEA), although the risk of stroke was higher with CAS, and the risk of myocardial infarction was higher with CEA. Given the large number of patients who are candidates for these procedures, an understanding of their relative cost and cost-effectiveness may have important implications for health care policy and treatment guidelines., Methods: We performed a formal economic evaluation alongside the CREST trial. Costs were estimated from all trial participants over the first year of follow-up using a combination of resource use data and hospital billing data. Patient-level health use scores were obtained using data from the SF-36. We then used a Markov disease-simulation model calibrated to the CREST results to project 10-year costs and quality-adjusted life expectancy for the 2 treatment groups., Results: Although initial procedural costs were $1025/patient higher with CAS, postprocedure costs and physician costs were lower such that total costs for the index hospitalization were similar for the CAS and CEA groups ($15 055 versus $14 816; mean difference, $239/patient; 95% CI for difference, -$297 to $775). Neither follow-up costs after discharge nor total 1-year costs differed significantly. For the CREST population, model-based projections over a 10-year time horizon demonstrated that CAS would result in a mean incremental cost of $524/patient and a reduction in quality-adjusted life expectancy of 0.008 years compared with CEA. Probabilistic sensitivity analysis demonstrated that CEA was economically attractive at an incremental cost-effectiveness threshold of $50 000/quality-adjusted life-year gained in 54% of samples, whereas CAS was economically attractive in 46%., Conclusions: Despite slightly lower in-trial costs and lower rates of stroke with CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

Object: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated that the risk of the primary composite outcome of stroke, myocardial infarction (MI), or death did not differ significantly in patients with an average surgical risk undergoing carotid artery stenting (CAS) and those undergoing carotid endarterectomy (CEA). However, the cost associated with CAS may limit its broad applicability. The authors' goal in this paper was to determine the cost-effectiveness of CAS with an embolic-protection device versus CEA in patients with moderate to severe carotid artery stenosis who are at average surgical risk., Methods: The probability of the primary outcome was obtained from the results of the CREST trial. The quality-adjusted life years (QALYs) associated with each treatment modality were estimated by adjusting for the incidence of each quality-adjusted outcome (QALY weights of ipsilateral stroke, MI, death, and postprocedure QALYs). The total cost associated with each intervention was derived from hospitalization cost and cost associated with primary outcomes including stroke, MI, and death in each group. Costs are expressed in US dollars accounting for inflation up to October 2010. Incremental cost-effectiveness ratios (ICERs) were estimated for the 4-year period after the procedure. All values are expressed as means and 95% confidence intervals., Results: The estimated net costs for patients after treatment with CAS and CEA after consideration of the primary outcome were $18,335 and $13,276, respectively, from the definitive presimulation analysis. Postsimulation values were $19,210 (range $18,264-$20,156) and $14,080 (range $13,076-$15,084), respectively. Overall, QALYs for the CAS and CEA groups were 0.712 and 0.702, respectively (ranging from 0.0 [death] to 0.815 [no adverse events]). The estimated ICER for CAS versus CEA treatment was $229,429., Conclusions: Although the CREST demonstrated equivalent results with CAS (compared with CEA) in patients at average surgical risk with severe carotid artery stenosis, broad applicability of CAS might be limited by the higher cost associated with this procedure.

Background: The purpose of this study was to evaluate the 10-year outcome of patients presenting with asymptomatic moderate carotid artery stenosis, and to determine which factors correlate with progression of disease to stroke or revascularization., Methods: A retrospective review of all new patients presenting with asymptomatic moderate carotid artery stenosis from July 1998 to December 2001 was undertaken. Patients were consecutively identified and included by using duplex ultrasonography to identify moderate carotid disease. Variables were recorded for all patient encounters through June 2010. The primary end point was occurrence of ipsilateral cerebrovascular stroke or revascularization event (SORE). Statin therapy and angiotensin blockade (STAB) were categorized as follows: STAB(0)-medical treatment with neither statin therapy nor angiotensin blockade, STAB(1)-treatment with only one of the two, STAB(2)-treatment with both. An amortized cost model analyzed the cost of SORE-free survival., Results: Over a 42-month period, 468 carotids in 366 patients with an average age of 69.0 ± 8.7 years were evaluated. Over a mean follow-up of 6.6 ± 2.7 years, SORE occurred in 150 (32.1%) carotid arteries. Hyperlipidemia was predictive of SORE (hazard ratio [HR]: 1.543, 95% confidence interval [CI]: 1.053-2.262, P = 0.03). Medical therapies protective against SORE were beta-blockade (HR: 0.612, 95% CI: 0.435-0.861, P < 0.05), STAB(1) (HR: 0.487, 95% CI: 0.336-0.706, P < 0.01), and STAB(2) (HR: 0.149, 95% CI: 0.089-0.248, P < 0.01). At 10 years, SORE-free survival in STAB(2) was 82.7% ± 4.6%, STAB(1) was 56.3% ± 5.0%, and STAB(0) was 29.3% ± 5.4% (P < 0.01). The cost per SORE-free year in STAB(2) was $1,695.40 ± $275.60, STAB(1) was $3,916.80 ± $605.44, and STAB(0) was $4,126.40 ± $427.23 (P < 0.01)., Conclusion: These data demonstrate the clinical and financial advantage of using both statin therapy and angiotensin pathway blockage in patients with asymptomatic moderate carotid artery stenosis., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

The recent American College of Cardiology/American Heart Association guideline recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients. This and the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) form the basis for seeking more liberalized indications and reimbursement for CAS. For the years 2005-2007, >130,000 carotid interventions/year were performed, 88.6% of which were CEAs and 11.4% were CAS. For the same years, each CAS procedure had on average $12,000-$13,500 more expensive mean total hospital charges than each CEA. If the percentages of CAS and CEA had been equal (ie, 50% CAS and 50% CEA), this would translate into an additional $2,000,000,000 in charges for these 3 years. It seems unreasonable to approve enhanced reimbursement for CAS at this time, especially since the large incremental costs would go to support CAS procedures that are inferior in most symptomatic patients and possibly unnecessary in most asymptomatic patients., (Published by Mosby, Inc.)

Background: We estimated the costs to the Danish National Health Service of preventing stroke due to carotid artery stenosis by carotid endarterectomy (CEA), including costs of identifying patients, Doppler ultrasound (DUS) examination and CEA., Methods: Estimations are based on patients with stroke, transient ischemic attacks (TIA) or amaurosis fugax referred for carotid DUS in the municipality of Frederiksberg, Denmark (127,184 residents), within an 18-month period in 2008-2009., Results: In total, 372 patients with stroke (n = 194), TIA (n = 157) or amaurosis fugax (n = 21) were referred for DUS. We identified 12 patients with 50-70% stenosis and 20 patients with >70% stenosis. Six had CEA, all of whom had stenosis >70%. Waiting time from symptom to CEA was a median of 38 days. Costs of preventing 1 recurrent stroke in the study period [number needed to treat (NNT) = 13] was in the range of EUR 207,675-333,918. If CEA had been performed within 2 weeks after onset of symptoms (NNT = 4), costs would be in the range of EUR 63,900-102,744., Conclusion: Costs of preventing stroke by CEA were high. Substantial reductions of costs (by about 2/3) can be achieved if CEA is performed <2 weeks after the ischemic event., (Copyright © 2012 S. Karger AG, Basel.)

Stroke is the third most common cause of death in North America and ever year approximately 700,000 new strokes are reported in the United States. Seventy-five percent of these occur in the distribution of the carotid arteries. Among strokes of a thromboembolic etiology, carotid occlusive disease is the most common cause. As many as 150,300 stroke-related fatalities are documented annually, with a total cost for the health-care system of approximately $ 18 billion per year. This review will focus on the different pathomorphologic aspects of carotid plaque, outlining the similarities and differences with the coronary plaque, with particular attention on how intravascular imaging may contribute to a better stratification of the patient treatment.

Background: The use of carotid stenting is rising across the United States. How physician specialty relates to its utilization rates or outcomes is uncertain., Methods: We performed an observational analysis of fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007 in 306 hospital referral regions (HRRs). We first determined how frequently carotid stenting was performed by different specialists within each HRR and then used multivariable regression models to compare population-based utilization rates and 30-day outcomes for this procedure across HRRs based on the proportion performed by cardiologists, surgeons, radiologists, or a mix of specialists., Results: In 272 HRRs where at least 15 procedures were performed during the study period, we identified 28 700 carotid stenting procedures performed by 2588 operators. While cardiologists made up approximately one-third of these operators, they were responsible for 14 919 (52.0%) procedures. Significant differences were noted in the characteristics of patients treated by cardiologists compared with other specialties, including higher rates of invasive cardiac procedures and lower rates of acute stroke or transient ischemic attacks in the 180 days prior to carotid stenting. Population-based utilization rates were significantly higher in HRRs where cardiologists performed most procedures relative to HRRs where most were done by other specialists or a mix of specialists (P < .001). In contrast, risk-standardized outcomes did not differ across HRRs based on physician specialty., Conclusions: Carotid stenting is being performed by operators from diverse specialties. Hospital referral regions where cardiologists perform most procedures have higher population-based utilization rates with similar outcomes.

Background: Although duplex ultrasonography (DU) can readily identify progression of carotid stenosis, controversy regarding the natural history of asymptomatic carotid stenosis as well as the need and appropriate interval for carotid DU surveillance still exists. Furthermore, consensus has not yet been made in the surgical literature regarding the usefulness, cost-effectiveness, or timing of DU surveillance after carotid endarterectomy (CEA). The purpose of this study was to determine how often DU surveillance for asymptomatic carotid disease or postintervention stenosis resulted in any change in the patient's clinical management, how many strokes were prevented by DU surveillance, and the cost of such a DU surveillance program per stroke prevented., Methods: We reviewed a 9-year vascular surgical database to identify all patients enrolled in a carotid DU surveillance program for asymptomatic carotid stenosis or following CEA between January 1, 2000, and December 31, 2008. The number of duplex scans and CEAs performed in those patients through March 2010 was also determined. The results of the Asymptomatic Carotid Atherosclerosis Study were then used to estimate the number of strokes prevented by CEA in the study population. Reimbursement data were assessed to calculate the average cost of each DU and the cost of the DU surveillance program for each stroke prevented., Results: During the study period, there were 11,531 carotid duplex scans performed on 3,003 patients (mean: 3.84 scans per patient) who had been enrolled in the DU surveillance program. CEA for asymptomatic carotid stenosis was performed on 225 (7.5%) patients. The DU surveillance program prevented approximately 13 strokes (871 carotid duplex scans per stroke prevented). The mean cost of each duplex scan was $332 ± 170. The total cost of the DU surveillance program was approximately $3,830,000 or $290,000 per stroke prevented., Conclusions: Although a carotid DU surveillance program generates substantial revenue for a vascular surgery practice, it is costly and inefficient. A reappraisal of the "value" of carotid DU surveillance in stroke prevention is warranted. Consideration should be given to eliminating routine surveillance of postendarterectomy carotids in the absence of contralateral disease and limiting the number of DU surveillance studies for asymptomatic carotid disease., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: The benefit of carotid endarterectomy (CEA) over best medical therapy was established using intra-arterial angiography (IAA) for patient selection. Its cost, availability, and risk together with the emergence of newer imaging modalities have led to its replacement in the routine assessment of internal carotid artery (ICA) stenosis. The relative performance of these methods should dictate the optimum imaging strategy in symptomatic patients., Methods: A previous meta-analysis (NIHR Health Technology Assessment Programme) was reviewed. Medline and PubMed search was performed for relevant publications since 2006 together with a review of the references in retrieved publications., Results: Compared to IAA, the sensitivity and specificity for noninvasive imaging of a ≥70% to 99% ICA stenosis are duplex ultrasound (DUS): 0.89 (0.85-0.92) and 0.84 (0.77-0.89); time-of-flight magnetic resonance angiography (TOF-MRA): 0.88 (0.82-0.92) and 0.84 (0.76-0.97); contrast-enhanced MRA (CE-MRA): 0.94 (0.88-0.97) and 0.93 (0.89-0.96); and computed tomography angiography: 0.77 (0.68-0.84) and 0.95 (0.91-0.97), respectively. A policy of initial DUS followed by confirmatory CE-MRA best matches patient selection by arteriography. Single modality imaging for 50% to 69% ICA stenoses suggests reduced reliability resulting in more inappropriate operations., Conclusions: DUS is the optimum screening tool due to its sensitivity and specificity, availability, and low cost. When CEA appears indicated, confirmatory imaging with CE-MRA is the most reliable and cost-effective method of investigation., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)