Objective: Transcarotid artery revascularization (TCAR) using reversal of flow has been shown to be a safe and effective means of treating carotid artery stenosis. However, no real-world analysis of the… Click to show full abstract
Objective: Transcarotid artery revascularization (TCAR) using reversal of flow has been shown to be a safe and effective means of treating carotid artery stenosis. However, no real-world analysis of the cost of using TCAR instead of carotid endarterectomy (CEA) for high-risk carotid stenosis has been performed. Methods: A retrospective, single-center analysis was performed comparing demographics, complications, and costs for patients with Medicare-defined high-risk characteristics undergoing TCAR vs CEA from January 2014 to June 2017. Direct costs were obtained from the hospital finance department. Costs were adjusted to 2017 dollars and are reported as median values. Results: There were 44 patients who underwent high-risk CEA and 46 patients who underwent TCAR. There were no significant differences in overall demographics or comorbidities. No difference with respect to symptomatic status (CEA, 36.4%; TCAR, 45.7%; P 1⁄4 .496) or treatment of restenosis (CEA, 11.4%; TCAR, 13%; P 1⁄4 1.0) was noted. Length of stay was also not different (CEA, 3.4 days; TCAR, 2.9 days; P 1⁄4 .65). The 30-day composite outcome of stroke, myocardial infarction, and death was similar between the groups (CEA, 4.6%; TCAR, 2.2%; P 1⁄4 .612). TCAR had lower surgery time (CEA, 137 minutes vs 83 minutes; P < .001). Overall median hospital stay cost for CEA and TCAR was $5093.62 and $10490.18 (P < .001), respectively. The median operating room cost for CEA ($2705.24) was lower than for TCAR ($8974.65), with most of the cost difference explained by operating room supplies (CEA, $780; TCAR, $6258); P < .001. All other major sources of hospital costs, including intensive care unit, pharmacy, laboratory tests, radiology, room and board, and ancillary costs, were similar between the groups. Conclusions: Compared with CEA, total direct costs are higher for TCAR, with most related to operating room supply costs. However, based on the 2017 Medicare fee schedule, the higher reimbursement for carotid stenting nearly negates this difference. Additional studies evaluating the financial impact of shorter surgery time as well as clinical outcomes are necessary to evaluate the cost-effectiveness between these two procedures.