Financial implications of post-transcarotid artery revascularization duplex surveillance

This study analyzes the financial and clinical implications of routine post-transcarotid artery revascularization (TCAR) surveillance (PTS). In this retrospective analysis, patients who underwent TCAR in a single institution during an 8-year period (2016 to 2024) were included. All patients underwent postoperative duplex ultrasound (DUS) repeated at 1, 6, and every 12 months. Previously validated carotid DUS criteria were used to define in-stent restenosis. Hospital charges for carotid DUS were captured to estimate charges for long-term PTS. The number of duplex examinations was used to calculate cost charge per reimbursement. A total of 301 patients with TCAR were analyzed. In a mean follow-up of 30 months, 21 patients had >50% in-stent restenosis (7%). Of these, 9 were associated with >80% and only 2 had ipsilateral strokes. The rates of freedom from >50% and >80% restenosis at 12, 24, and 36 months were 94%, 90%, and 89% and 97%, 96%, and 95%, respectively. The total number of duplex examinations was 938. Estimated hospital charges for all DUS examinations were $1,017,730. However, the estimated reimbursement was $272,345. Based on the Society for Vascular Surgery guideline recommendation that most asymptomatic (>70% to 80%) restenosis should be treated medically and do not need re-intervention, this surveillance would have detected only 2 patients associated with >80% restenosis. If the patients had undergone re-intervention, 2 potential strokes at the cost of $1,017,730 per $272,345 reimbursement may have been prevented. Based on this study, PTS is probably costly and perhaps should be performed selectively. Further studies are needed to clarify this finding.