Abstract
Introduction: The Stenting versus Endarterectomy for treatment of carotid stenosis trial (CREST) demonstrated that the risk of the composite primary outcome of stroke, myocardial infarction (MI), or death did not differ significantly in the average surgical risk patients undergoing carotid-artery stent placement (CAS) and those undergoing carotid endarterectomy (CEA). However, the cost associated with CAS may limit its broad applicability. Objective: To determine the cost-effectiveness of CAS with emboli-protection device versus CEA in average surgical risk patients with moderate-severe carotid stenosis. Methods: The probability of primary endpoint was obtained from the results of the CREST trial. The quality-adjusted life year (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 post-procedure QALYs). Total cost associated with each intervention was derived from hospitalization cost and cost associated with primary endpoints 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 four year period following the procedure. All values are expressed as means and 95% percentile intervals. Results: The estimated net costs for patients after treatment with CAS and CEA after consideration of primary endpoint were $ 18,335 and $ 13,276, respectively from definitive pre-simulation analysis. Post simulation values were $19,210 ($18,264- $ 20,156) and $14,080 ($13,076 - $15,084). Overall QALYs for the CAS and CEA groups were 0.712 and 0.702 respectively (ranging from 0.0 meaning death to 0.815 meaning 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 average surgical risk patients with severe carotid stenosis, broad applicability of CAS might be limited by the higher cost associated with this procedure.
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