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Published on: May 14, 2013
Cost-Effectiveness of Carotid Endarterectomy vs. Carotid Stenting: a Systematic Review and Meta-Analysis
Yash Akkara1, Joshua J Hon1, Mahathir Ahmed1
1Imperial College School of Medicine, London, England.
Insights
Carotid endarterectomy (CEA) offers marginally better cost-effectiveness than carotid artery stenting (CAS) for carotid artery stenosis, despite longer procedures. Cost should not be the sole deciding factor.
Area of Science:
- Vascular Surgery
- Health Economics
- Clinical Outcomes
Background:
- Carotid artery stenosis requires effective treatment, with carotid endarterectomy (CEA) and carotid artery stenting (CAS) as established interventions.
- Evaluating the comparative cost-effectiveness of CEA versus CAS is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To conduct a systematic review and meta-analysis comparing the cost-effectiveness of CEA and CAS for treating carotid artery stenosis.
- To analyze procedural outcomes, complication rates, and associated costs at one year postoperatively.
Main Methods:
- Systematic literature search of PubMed, MEDLINE, and Embase following PRISMA guidelines.
- Inclusion of studies with ≥20 participants (≥16 years) reporting 1-year postoperative costs.
- Statistical analysis using a random-effects model, with costs adjusted to 2024; bias assessed using Cochrane Risk of Bias 2.0 and Newcastle-Ottawa Scale.
Main Results:
- Seven studies involving 6493 participants (3511 CAS, 2932 CEA) were analyzed.
- CEA had significantly longer procedure times (191.92 vs. 77.5 min) and hospital stays (3.13 vs. 2.60 days) than CAS.
- Mean 1-year costs were marginally lower for CEA ($21,264.03) vs. CAS ($21,433.14), with CEA showing marginally better cost-effectiveness (ratio=1.019).
Conclusions:
- Carotid endarterectomy (CEA) demonstrates marginally superior cost-effectiveness compared to carotid artery stenting (CAS), particularly in high-volume surgical centers.
- While CAS offers shorter procedure times and hospital stays, potentially improving productivity, cost should not be the primary determinant in treatment selection.
- Both CEA and CAS are viable options, with the choice influenced by a balance of cost-effectiveness, procedural efficiency, and patient-specific factors.
Introduction:
Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are gold-standard treatments of carotid artery stenosis. This study aims to identify the cost-effectiveness of CEA vs CAS.
Methods:
Studies were screened through PubMed, MEDLINE, and Embase using PRISMA guidelines, and required ≥ 20 participants who were ≥ 16 years, alongside costs at 1-year postoperatively. The Shapiro-Wilk test, independent sample t-tests, ANOVA, and Spearman's R were used, with costs adjusted to 2024. A random-effects model was used to compare cost-effectiveness. Bias assessment was according to the Cochrane Risk of Bias 2.0 tool and the Newcastle-Ottawa Scale.
Results:
7 studies were included, with a sample of 6493 participants (3418 M, 3075 F). 2932 and 3511 participants underwent CEA and CAS respectively. CEA reported a significantly longer mean length of procedure (191.92 vs. 77.5 min, p < 0.0001) and length of stay (3.13 vs. 2.60 days, p < 0.0001) vs. CAS. The mean adjusted cost of CEA and CAS were $18156.60 (6466) and $17711.01 (5511) respectively. Studies reported lower risks of stroke (2.12% vs. 3.65%, p < 0.001), higher risks of myocardial infarctions (1.70% vs. 1.42%, p < 0.01), and higher risks of other complications for CEA vs. CAS respectively. The expected 1-year cost of CEA was marginally lower than CAS ($21264.03 vs. $21433.14, p < 0.05). The cost-effectiveness of CEA was marginally better than CAS (ratio = 1.019, 95% CI [1.017, 1.020)].
Conclusions:
CEA provides marginally improved cost-effectiveness over CAS, providing long-term cost benefits to centers with large surgical volumes. However, shorter procedural times and inpatient stays with CAS may improve overall productivity. Cost should hence not be a deciding factor when choosing between CEA and CAS.
