Cost-Effectiveness of Carotid Endarterectomy vs. Carotid Stenting: a Systematic Review and Meta-Analysis

Abstract

Introduction Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are gold-standard treatments of carotid artery stenosis. This study aims to identify the cost-effectiveness of CEA vs CAS. Methods Studies were screened through PubMed, MEDLINE, and Embase using PRISMA guidelines, and required ≥ 20 participants who were ≥ 16 years, alongside costs at 1-year postoperatively. The Shapiro–Wilk test, independent sample t-tests, ANOVA, and Spearman’s R were used, with costs adjusted to 2024. A random-effects model was used to compare cost-effectiveness. Bias assessment was according to the Cochrane Risk of Bias 2.0 tool and the Newcastle–Ottawa Scale. Results 7 studies were included, with a sample of 6493 participants (3418 M, 3075 F). 2932 and 3511 participants underwent CEA and CAS respectively. CEA reported a significantly longer mean length of procedure (191.92 vs. 77.5 min, p < 0.0001) and length of stay (3.13 vs. 2.60 days, p < 0.0001) vs. CAS. The mean adjusted cost of CEA and CAS were $18156.60 (6466) and $17711.01 (5511) respectively. Studies reported lower risks of stroke (2.12% vs. 3.65%, p < 0.001), higher risks of myocardial infarctions (1.70% vs. 1.42%, p < 0.01), and higher risks of other complications for CEA vs. CAS respectively. The expected 1-year cost of CEA was marginally lower than CAS ($21264.03 vs. $21433.14, p < 0.05). The cost-effectiveness of CEA was marginally better than CAS (ratio = 1.019, 95% CI [1.017, 1.020)]. Conclusions CEA provides marginally improved cost-effectiveness over CAS, providing long-term cost benefits to centers with large surgical volumes. However, shorter procedural times and inpatient stays with CAS may improve overall productivity. Cost should hence not be a deciding factor when choosing between CEA and CAS.

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