Carotid endarterectomy: the financial impact of practice changes

Economic impact of endarterectomy vs carotid artery stenting: a one year, single centre study

AIMS

Carotid artery stenting (CAS) has been suggested by some clinicians as an alternative to endarterectomy (CEA), especially in some specific subgroups of the population. The aim of this study is to evaluate the costs of these two procedures.

METHODS AND RESULTS

A review of costs was performed on all patients who underwent elective treatment of carotid artery stenosis between January and December 2006 (184 CAS vs 97 CEA). Clinical data had been prospectively gathered from both the CAS and the CEA groups, while financial data was obtained retrospectively to match hospital admissions with the generated charge from the hospital business office. In this series there was one major event in CEA and one transient ischaemic attacks (TIA) in CAS. One death procedure-related event occurred in CEA. The mean total cost associated with a single CEA was slashed integral 3,897.86, whereas the cost associated with CAS was slashed integral 3,806.66. It was apparent that the increasing costs involved in purchasing material for CAS, were balanced by the lower spending for hospital stay.

CONCLUSIONS

Costs for CAS and CEA are comparable. In our experience, the choice between CAS and CEA is based on the comorbidity of the patient, the type of the lesion and the preferences of the patient, without economic criteria being important.

Short-stay carotid endarterectomy in a tertiary-care Veterans Administration hospital

BACKGROUND

This study focused on 200 carotid endarterectomies (CEA) performed at our Veterans Administration Hospital (VAH) to determine whether 1-day hospitalization after CEA is safe and the degree to which it can be achieved.

METHODS

Over 36 months, 200 CEAs were performed for asymptomatic stenosis (n = 104), transient ischemic attacks (n = 68), and stroke (n = 28). General anesthesia was used in 189 procedures.

RESULTS

The hospital stay was 1 day for 132 procedures and more than 1 day in 68 CEAs. The average stay was 1.69 +/- 1.5 days. After surgery there were 3 strokes, 5 hematomas that required evacuation, and 5 myocardial infarctions. There were no deaths. Four patients were readmitted in the 1-day and the greater than 1-day stay groups. History of myocardial infarction, renal insufficiency, longer operative time, and complications correlated with a greater than 1-day stay (P <0.05).

CONCLUSION

A 1-day hospital stay is safe and practical in a VAH setting, resulting in good clinical outcomes.

Carotid Angioplasty and Stenting versus Carotid Endarterectomy for Treatment of Asymptomatic Carotid Stenosis: A Randomized Trial in a Community Hospital

OBJECTIVE

Carotid endarterectomy (CEA) is effective in reducing the risk of stroke in individuals with more than 60% carotid stenosis. Carotid angioplasty and stenting (CAS) has been proffered as effective and used in treating individuals with asymptomatic carotid stenosis despite the absence of proven clinical equivalency. This randomized trial was designed to explore the hypothesis that CAS is equivalent to CEA for treating asymptomatic carotid stenosis.

METHODS

A total of 85 individuals presenting with asymptomatic carotid stenosis of more than 80% were selected randomly for CAS or CEA and followed up for 48 months.

RESULTS

Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique, as determined by carotid ultrasonography. No major complications such as cerebral ischemia or death occurred. Procedural complications associated with CAS (n = 5) were hypotension and/or bradycardia; those concomitant with CEA (n = 3) were cervical nerve injury or complications related to general anesthesia (n = 4). Both procedures were well tolerated in the context of pain and discomfort. Hospital stay was similar in the two groups (mean, 1.1 versus 1.2 d). The occurrence of complications associated with CAS or CEA prolonged hospitalization by 3 days (mean, 4.0 versus 4.5 d). Return to full activity was achieved within 1 week by more than 85% of patients; all returned to their usual lifestyle by 2 weeks. Although hospital charges were slightly higher for CAS, costs were similar.

CONCLUSION

CAS and CEA may be equally effective and safe in treating individuals with asymptomatic carotid stenosis.

Improvement in accuracy of diagnosis of carotid artery stenosis with duplex ultrasound scanning with combined use of linear array 7.5 MHz and convex array 3.5 MHz probes: validation versus 489 arteriographic procedures

OBJECTIVE

Validity of a method to improve the accuracy of carotid artery duplex scanning was tested in comparison with arteriography.

STUDY DESIGN

In 489 patients who had not previously undergone arteriography, 978 carotid arteries were examined with duplex ultrasound scanning. In method A, a linear array 7.5 MHz transducer with pulsed-wave 4.7 MHz Doppler scanning was used. For the diagnosis and grading of carotid stenosis, peak systolic and end-diastolic velocity of the Doppler waves were recorded. Method B consisted of complete ultrasound imaging and color-flow mapping with a convex array 3.5 MHz transducer with pulsed-wave 2.8 MHz Doppler scanning in all patients who had previously undergone method A. Further velocity measurements were performed at the sites of stenosis. The results of methods A and B were compared with data from neurologic assessment and arteriographic studies.

RESULTS

Method B showed significantly higher diagnostic agreement with arteriography than did method A (K 95% confidence interval [CI], 0.87-0.93 vs 0.79-0.85; P <.05), and the number of mistakes in grading stenosis was significantly lower (primarily because of decreased overestimation) in patients with internal carotid kinking (>60 degrees of angulation) (P <.05), distal stenosis (>20 mm from bifurcation) (P <.01), or wide acoustic shadowing (>1 cm) (P <.01) and in those without these conditions (P <.05). Compared with arteriography, diagnostic accuracy with the new method proved higher for carotid stenoses 50% or greater, 60% or greater, 70% or greater, and 80% or greater; no statistically significant difference was found for carotid stenosis 96% or greater or for carotid occlusion. Compared with data from neurologic assessment and arteriography, method B proved more accurate than method A in designating patients for carotid endarterectomy (P =.014).

CONCLUSIONS

The new method significantly improved diagnostic reliability of duplex ultrasound scanning, especially in carotid arteries with kinking, distal stenosis, or wide acoustic shadowing (32.2% of all arteries studied). In clinical practice, we suggest additional use of a lower frequency transducer in cases in which these three conditions are found or suspected at first scanning.