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Research ArticleInterventional

When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective

M.A. Almekhlafi, M.D. Hill, S. Wiebe, M. Goyal, D. Yavin, J.H. Wong and F.M. Clement
American Journal of Neuroradiology February 2014, 35 (2) 327-332; DOI: https://doi.org/10.3174/ajnr.A3682
M.A. Almekhlafi
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
eDepartment of Internal Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia.
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M.D. Hill
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
bMedicine (M.D.H.)
cCommunity Health Sciences (M.D.H., S.W., F.M.C.)
dRadiology (M.G., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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S. Wiebe
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
cCommunity Health Sciences (M.D.H., S.W., F.M.C.)
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M. Goyal
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
dRadiology (M.G., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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D. Yavin
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
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J.H. Wong
aFrom the Departments of Clinical Neurosciences (M.A.A., M.D.H., S.W., M.G., D.Y., J.H.W.)
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F.M. Clement
cCommunity Health Sciences (M.D.H., S.W., F.M.C.)
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Abstract

BACKGROUND AND PURPOSE: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy.

MATERIALS AND METHODS: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial.

RESULTS: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (−0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy.

CONCLUSIONS: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

ABBREVIATIONS:

BURST
Burden of Ischemic Stroke
CAS
carotid angioplasty and stenting
CEA
carotid endarterectomy
CREST
Carotid Revascularization Endarterectomy versus Stenting Trial
EVA-3S
Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis
MI
myocardial infarction
QALY
quality-adjusted life years
SAPPHIRE
Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy
  • © 2014 by American Journal of Neuroradiology
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American Journal of Neuroradiology: 35 (2)
American Journal of Neuroradiology
Vol. 35, Issue 2
1 Feb 2014
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When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective
M.A. Almekhlafi, M.D. Hill, S. Wiebe, M. Goyal, D. Yavin, J.H. Wong, F.M. Clement
American Journal of Neuroradiology Feb 2014, 35 (2) 327-332; DOI: 10.3174/ajnr.A3682

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When Is Carotid Angioplasty and Stenting the Cost-Effective Alternative for Revascularization of Symptomatic Carotid Stenosis? A Canadian Health System Perspective
M.A. Almekhlafi, M.D. Hill, S. Wiebe, M. Goyal, D. Yavin, J.H. Wong, F.M. Clement
American Journal of Neuroradiology Feb 2014, 35 (2) 327-332; DOI: 10.3174/ajnr.A3682
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