Robotic carotid artery stenting: a multicenter, propensity score–matched analysis of clinical outcomes and cost-effectiveness

Abstract

OBJECTIVE Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exist for patients who have undergone robotic versus manual CAS. In addition, no data exist comparing the costs of manual and robotic CAS. METHODS All robotic CAS cases at two academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration by using time-driven activity-based cost analysis. RESULTS A total of 24 robotic CAS operations were performed between 2019 and 2023. Comorbidities and baseline procedural characteristics were well matched between robotic and manual cases. Unplanned manual conversion was observed in only 1 robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs 19.2 minutes; p < 0.001). Robotic procedure time (88.9 ± 18.2 minutes) was significantly (p = 0.003) longer than manual time (68.72 ± 22.4 minutes). Health personnel costs ($1589.71 ± $176.92 vs $1375.99 ± $233.39, p = 0.005); supply costs ($3918.25 ± $421.20 vs $2152.74 ± $1030.26, p < 0.001); and total procedure costs ($5306.11 ± $608.95 vs $3437.56 ± $1165.67, p < 0.001) were greater for robotic CAS. CONCLUSIONS In the first multicenter study and largest sample to date, the authors show that robotic CAS, with a low rate of procedural failure and postoperative complications, is safe and feasible. In addition, robotic CAS achieves comparable clinical outcomes to manual CAS. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX system. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Robotic CAS failed to show superiority to manual CAS. These findings set a foundation for randomized controlled trials of robotic CAS, and also highlight the need for further studies to optimize robotic CAS and reduce its associated costs.