COST-EFFECTIVENESS OF CAROTID ENDARTERECTOMY

CAROTID ENDARTERECTOMY (CEA) reduces the risk of stroke in symptomatic patients with high-grade carotid stenosis. In this study, we evaluate d the long-term, societal cost-benefit ratio of endarterectomy using a decision analysis model. We reviewed the results of 150 CEAs performe d at an academic center and established a Markov model comparing cohor ts of patients who experienced transient ischemic attacks and then und erwent observation, aspirin therapy, or CEA. The cost-effectiveness of CEA was estimated using perioperative complication rates from our rev iew and from the North American Symptomatic Carotid Endarterectomy Tri al. Stroke and mortality rates were estimated from the literature. Cos t estimates were based on medicare reimbursement data. Among the 150 C EAs reviewed, complications included major stroke (0.67%), minor strok e (1.33%), myocardial infarction (1.33%), pulmonary edema (0.67%), and wound hematoma (3.33%). There were no deaths or intracerebral hemorrh ages. Using complication rates from our review, CEA produced cost savi ngs of $5730.62 over the cost of observation and $3264.66 over the cos t of aspirin treatment. CEA extended the average quality-adjusted life expectancy 15.8 months over that of observation and 13.2 months over that of aspirin. Substituting the North American Symptomatic Carotid E ndarterectomy Trial results, CEA yielded savings of $2997.50 over the cost of observation and $531.54 over the cost of aspirin. Quality-adju sted life expectancy was extended 13.8 months compared with observatio n and 11.2 months compared with aspirin therapy. This analysis demonst rates that when performed with low perioperative morbidity and mortali ty rates, CEA is a highly cost-effective therapy for symptomatic carot id stenosis and results in substantial societal cost and life savings.