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Meta‐analysis of the costs of carotid artery stenting and carotid endarterectomy. BJS 2017; 104: 1284-1292.

Published: 7th August 2017

Authors: E. E. de Vries, V. G. M. Baldew, H. M. den Ruijter, G. J. de Borst

Background

Carotid artery stenting (CAS) is currently associated with an increased risk of 30‐day stroke compared with carotid endarterectomy (CEA), whereas both interventions seem equally durable beyond the periprocedural period. Although the clinical outcomes continue to be scrutinized, there are few data summarizing the costs of both techniques.

Method

A systematic search was conducted in MEDLINE, Embase and Cochrane databases in August 2016 identifying articles comparing the costs or cost‐effectiveness of CAS and CEA in patients with carotid artery stenosis. Combined overall effect sizes were calculated using random‐effects models. The in‐hospital costs were specified to gain insight into the main heads of expenditure associated with both procedures.

Results

The literature search identified 617 unique articles, of which five RCTs and 12 cohort studies were eligible for analysis. Costs of the index hospital admission were similar for CAS and CEA. Costs of the procedure itself were 51 per cent higher for CAS, mainly driven by the higher costs of devices and supplies, but were balanced by higher postprocedural costs of CEA. Long‐term cost analysis revealed no difference in costs or quality of life after 1 year of follow‐up.

Conclusion

Hospitalization and long‐term costs of CAS and CEA appear similar. Economic considerations should not influence the choice of stenting or surgery in patients with carotid artery stenosis being considered for revascularization.

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Your comments

2 Comments

ANTONIO STERPETTI

2 months ago

I read with the interest the paper by de Vries et al. In their study they found no difference between the costs of carotid stenting and endarterectomy. Carotid revascularization is aimed to prevent the possibility of stroke. Every economic analysis about prevention of a phenomenon cannot be restricted to the maneuver per se, but it should include inevitably the costs related to the possibility of failure in preventing the phenomenon itself.

Carotid stenting in patients with symptomatic carotid disease has been shown to have higher perioperative stroke rates than carotid endarterectomy, and in the long term there is a higher possibility of stroke. The costs of a stroke in the perioperative period or in the long term, is inevitably very high from all points of view. Carotid stenting is associated with lower rates of perioperative nerve complications and minor myocardial infarction in comparison to carotid endarterectomy (1,2): how these complications compare with a stroke by an economic point of view is difficult to define, but for sure there are major differences. In patients with asymptomatic carotid stenosis, so far, no difference has been found in postoperative complications, however, long term results are not well defined.

Carotid stenting offers many theoretical potentials in asymptomatic patients, in whom medical therapy could have a major role. It is difficult to understand how a plaque which has given symptoms, in general embolic in nature, is neutralized if the plaque remains in situ (3,4,5).

Antonio V Sterpetti
University of Rome Sapienza
Policlinico Umberto I
Viale del Policlinico
00167 Rome
Italy
antonio.sterpetti@uniroma1.it

References:
1. Sardar P, Chatterlee S, Aronow HD et al. “Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials”. J Am Coll Cardiol 2017; 69: 2266-2275.
2. Vincent S, Eberg M, Eisenberg MJ, Filon KB. “Meta-analysis of randomized controlled trials comparing the long term outcomes of carotid artery stenting versus endarterectomy”. Circ Cardiovasc Qual Outcomes 2015; 8: S99-108.
3. Sterpetti AV, Schultz RD, Feldhuas RJ et al. “Ultrasonographic characteristics of the carotid plaque and the risk of subsequent neurologic deficits”. Surgery 1988; 104: 652-660.
4. Sterpetti AV, Huinter WJ, Schultz RD. “The importance of ulceration of carotid plaque in determining symptoms of cerebral ischemia”. J Cardiovasc Surg 1991; 32: 154-8.
5. Sterpetti AV. “A different point of view on carotid stenting”. Ann Vasc Surg 2013; 27: 391-2.

BJS admin

1 week ago

We thank Prof. AV Sterpetti for his interest in our study, and we confirm that the most important outcome measure of a comparison between two interventions is always clinical efficacy and safety, which in case of carotid revascularization is stroke and stroke-related death prevention. We also recognise that occurrence of complications is associated with higher costs, and thus should be taken into account when calculating intervention-related costs.

The perioperative complication risk of CAS is indeed higher compared to CEA, but is mainly based on a larger number of non-disabling strokes (1), which occur predominantly on the day of the procedure, and are most often caused by a haemodynamic mechanism (2). However, when excluding periprocedural strokes, there does not seem to be a difference in the long-term risk of stroke between both interventions (3).

In our analysis on costs of hospital admission, costs of prolonged admission due to periprocedural complications were taken into account. The analysis on long-term costs (including merely two randomised trials) also included costs associated with complications, such as costs for re-admission, visits to outpatient clinics and re-interventions. Therefore we conclude that, when including costs affiliated with complications on short- and long-term, costs for CAS and CEA are equal.

Most likely, future studies will point out patient subgroups which will benefit from specific carotid interventions. For example, it seems that CAS in the very acute phase might be hazardous due to increased vulnerability of the atherosclerotic plaque (4,5). For asymptomatic patients, in our opinion, the current priority should be to define the subset of patients which really benefits from revascularization over best medical treatment.

Evelien E. de Vries
Gert J. de Borst

University Medical Centre Utrecht
Utrecht University
Domplein 29
3512 JE Utrecht
Netherlands
G.J.deBorst-2@umcutrecht.nl

References:
1. Sardar P, Chatterlee S, Aronow HD et al. Carotid artery stenting versus endarterectomy for stroke prevention: a meta-analysis of clinical trials. J Am Coll Cardiol 2017; 69: 2266-2275.
2. Huibers A, Calvet, D, Kennedy F et al. Mechanism of procedural stroke following carotid endarterectomy or carotid artery stenting within the International Carotid Stenting Study (ICSS) randomised trial. Eur J Vasc Endovasc Surg 2015; 50:281-288.
3. De Borst GJ, Naylor AR. In the end, it all comes down to the beginning! Eur J Vasc Endovasc Surg 2015; 50:271–272.
4. Rantner B, Goebel G, Bonati LH, Ringleb PA., Mas JL, Fraedrich G. The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms. J Vasc Surg 2013; 57: 619–626.
5. van Lammeren GW, den Ruijter HM, Vrijenhoek JE et al. Time-dependent changes in atherosclerotic plaque composition in patients undergoing carotid surgery. 2014. Circulation 2014; 129:2269-76.