What does this research mean for the field?

Best medical therapy reduces annual ipsilateral stroke risk in asymptomatic carotid disease to 0.5-1%, while carotid endarterectomy maintains 1-2% 30-day stroke or death rates in centers of excellence. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

The research aims to evaluate contemporary evidence regarding outcomes and cost-effectiveness of various treatments for carotid artery disease through a value-based lens.

February 28, 2026Open Access

A Contemporary Paradigm for Value-Based Medicine in the Management of Carotid Artery Disease

Key Result

Best medical therapy reduces annual ipsilateral stroke risk in asymptomatic carotid disease to 0.5-1%, with carotid endarterectomy showing 1-2% 30-day stroke/death rates in centers of excellence.

Key Points

The research aims to evaluate contemporary evidence regarding outcomes and cost-effectiveness of various treatments for carotid artery disease through a value-based lens.
Conducted a narrative review of guidelines and landmark trials
Analyzed peri-procedural safety and long-term outcomes
Compared ICERs across treatment options
Reviewed emerging risk models and AI integration
Best medical therapy is foundational, reducing stroke risk to approximately 0.5-1% for asymptomatic patients
CEAs have a 30-day stroke/death rate of ∼1-2% for asymptomatic disease
TF-CAS shows non-inferiority in asymptomatic patients compared to CEA, though with slightly more early non-disabling strokes
Integrating AI may enhance individualized treatment selection
Cost-effectiveness of TCAR varies by case mix and efficiency pathways

Structured PICO

What is the contemporary evidence on outcomes and cost-efficiency for BMT, CEA, TF-CAS, and TCAR in carotid artery disease?

Population

Patients with asymptomatic and symptomatic carotid artery disease

Intervention

Best medical therapy (BMT), carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR)

Comparator

Narrative comparison among treatment modalities

Outcome

Peri-procedural safety, long-term ipsilateral stroke, health-related quality of life, and incremental cost-effectiveness ratios (ICERs)composite

A value-based medicine approach to carotid artery disease prioritizes universal application of best medical therapy, selective revascularization, and transparent performance and cost tracking.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

ABSTRACTObjectives To synthesize contemporary evidence on outcomes and cost-efficiency for best medical therapy (BMT), carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR) in carotid artery disease (CAD) through a value-based medicine (VBM) lens. Methods Narrative review of major guidelines (SVS 2022; ESVS 2023; AHA/ASA 2021), landmark trials and registries (e.g., CREST, CREST-2, ACST-2, VQI, ROADSTER-era series), and recent economic evaluations. Endpoints included peri-procedural safety, long-term ipsilateral stroke, health-related quality of life, and incremental cost-effectiveness ratios (ICERs). Results BMT remains the foundation of high-value care and has reduced annual ipsilateral-stroke risk for many asymptomatic patients to roughly 0.5-1%. Contemporary centers of excellence for CEA report 30-day combined stroke/death ∼1-2% for asymptomatic and Conclusions A VBM approach to CAD prioritizes universal application of BMT, selective revascularization, and transparent performance/cost tracking. Maintaining periprocedural stroke/death ≤3% (asymptomatic) and ≤6% (symptomatic) maximizes quality-adjusted life-years per healthcare dollar. Future value gains are likely from precision, patient-individualized therapy driven by AI-enabled risk stratification, standardized short-stay care pathways, and performance-linked reimbursement.