Cost Analysis of Carotid Endarterectomy vs Transcarotid Artery Revascularization at a Single Tertiary Care Center

Transcarotid Artery Revascularization (TCAR) has been shown to be safe and effective for treatment of carotid artery stenosis, with comparable short-term outcomes with the surgical standard, carotid endarterectomy (CEA). Few peer-reviewed studies have been performed to evaluate the cost-effectiveness of these two procedures. The objective of this study was to compare cost-efficacy of these procedures at a single institution. A retrospective analysis was performed for patients receiving either TCAR or CEA at a single tertiary-care center from August 2018 to July 2023. Patient characteristics, demographics, and procedure cost data were extracted from the electronic medical record. Overall perioperative hospital costs were calculated using estimates derived from literature and adjusted for inflation. A subset of patient charts from June 2022 to July 2023 were used to calculate baseline procedure costs for TCAR and CEA cohorts, with individual implant costs from each chart added to obtain total estimated procedure cost. Patients converted from TCAR to CEA were excluded from procedure cost analysis. Of 157 patients, 51 received TCAR and 106 received CEA. Patients undergoing TCAR were significantly older (Table I) (74.0 vs 69.8 years; P = .0099), and more likely to have prior history of ipsilateral carotid intervention (21.6% vs 0.9%; P < .001), contralateral carotid intervention (25.5% vs 11.3%; P =0 .023), or neck surgery (33.3% vs 17.9%; P = .031). Procedure length was shorter in the TCAR group (107.59vs 132.45 minutes; P < .001). No differences were found in duration of post-procedure ICU or hospital stay, or in estimated total cost of stay, excluding cost of procedure ($5,846.03 for TCAR vs $5,628.97 for CEA; P = .8736). Of the 56 patients for whom procedure cost data was collected, TCAR was found to have a higher total procedure cost (Table II) ($9,113.71 for TCAR; $1,408.57 for CEA; P < .001). In this patient subset, total perioperative hospital stay including total procedure cost was significantly different ($14,090.42 for TCAR; $7,317.03 for CEA; P < .001). This pattern held true for the estimated procedure cost ($9,099.99 for TCAR; $1,417.77 for CEA; P < .001) and estimated total perioperative cost ($14,946.02 for TCAR; $7,046.74 for CEA; P < .001) in the larger cohort. This study found the cost to undergo TCAR was significantly higher than CEA for patients at this institution. When used to estimate total cost of a patient's stay, TCAR more than doubled the net cost of perioperative hospital stay. Further analysis is warranted to determine areas of optimization of costs associated with carotid revascularization.Table IDemographics, comorbidities, and admission dataTotal (N = 157), No. (%)CEA (n = 106), No. (%)TCAR (n = 51), No. (%)P-valueAge, years (±SD)71.2 (9.4)69.8 (9.4)74.0 (9.2).0099Sex Female57 (36.3)36 (34.0)21 (41.2).379 Male100 (63.7)70 (66.0)30 (58.8)Race White106 (67.5)63 (59.4)43 (84.3).006 Black12 (7.7)8 (7.6)4 (7.8) Asian5 (3.2)3 (2.8)2 (3.9) Hispanic1 (0.6)1 (0.9)0 (0) Other33 (21.0)31 (29.3)2 (3.9)Symptomatic Yes78 (49.7)58 (54.7)20 (39.2).069 No79 (50.3)48 (45.3)31 (60.8)Postoperative length of stay, days (±SD) Hospital2.04 (2.12)2.24 (2.20)1.82 (2.06).4599 ICU0.11 (0.36)0.10 (0.31)0.11 (0.42).9697Disposition Home143 (91.1)98 (92.5)45 (88.2).385 Rehab facility14 (8.9)8 (7.5)6 (11.8)History of CAD Yes80 (51.0)53 (50.0)27 (52.9).730 No77 (49.0)53 (50.0)24 (47.1)History of PAD/PVD Yes35 (22.3)25 (23.6)10 (19.6).575 No122 (77.7)81 (76.4)41 (80.4)History of HTN Yes138 (87.9)93 (87.7)45 (88.2).928 No19 (12.1)13 (12.3)6 (11.8)History of DM Yes53 (33.8)36 (34.0)17 (33.3).938 No104 (66.2)70 (66.0)34 (66.7)History of CKD Yes32 (20.4)22 (20.7)10 (19.6).867 No125 (79.6)84 (79.3)41 (80.4)History of COPD Yes18 (11.5)12 (11.3)6 (11.8).935 No139 (88.5)94 (88.7)45 (88.2)History of MI Yes29 (18.5)18 (17.0)11 (21.6).488 No128 (81.5)88 (83.0)40 (78.4)History of stroke/TIA Yes54 (34.4)41 (38.7)13 (25.5).103 No103 (65.6)65 (61.3)38 (74.5)Prior ipsilateral carotid intervention Yes12 (7.6)1 (0.9)11 (21.6).000 No145 (92.4)105 (99.1)40 (78.4)Prior contralateral carotid intervention Yes25 (15.9)12 (11.3)13 (25.5).023 No132 (84.1)94 (88.7)38 (74.5)Prior neck surgery Yes36 (22.9)19 (17.9)17 (33.3).031 No121 (77.1)87 (82.1)34 (66.7)Prior neck radiation Yes7 (4.5)3 (2.8)4 (7.8).154 No150 (95.5)103 (97.2)47 (92.2)Aspirin given preoperatively Yes141 (89.8)93 (87.7)48 (94.1).216 No16 (10.2)13 (12.3)3 (5.9)Statin given preoperatively Yes153 (97.5)105 (99.1)48 (94.1).066 No4 (2.6)1 (0.9)3 (5.9)Plavix given preoperatively Yes82 (52.2)44 (41.5)38 (74.5).000 No75 (47.8)62 (58.5)13 (25.5)Brilinta given preoperatively Yes6 (3.8)2 (1.9)4 (7.8).068 No151 (96.2)104 (98.1)47 (92.2)Procedure time, minutes (±SD) Incision to closure124.38 (43.49)132.45 (48.47)107.59 (23.26).0003 Total time in OR184.80 (46.73)190.07 (51.67)173.84 (32.03).0206 Open table in a new tab Table IIResults of cost analysisTotal (N = 57)CEA (n = 29)TCAR (n = 28)P-valueLength of stay, days (±SD) Hospital2.04 (2.12)2.24 (2.20)1.82 (2.06).4599 ICU0.11 (0.36)0.10 (0.31)0.11 (0.42).9697Estimated stay cost, dollars (±SD) Regular bed$ 4848.00 ($5073.71)$5302.66 ($5198.60)$4377.09 ($4991.35).4961 ICU bed$582.22 ($2014.32)$565.43 ($1694.06)$599.61 ($2332.13).9496 True procedure cost, dollars (±SD)$ 5261.14a ($4136.48)$1408.57a ($325.38)$ 9113.71 ($1991.18).000 Total cost excluding procedure (±SD)$5442.59 ($6552.31)$5908.46 ($6157.66)$4976.71 ($7006.33).5993 Total cost including procedure (±SD)$10,703.73a ($7489.57)$7317.03a ($6313.13)$14,090.42 ($7114.80).0002Length of stay, days (±SD) Hospital2.09 (2.27)2.02 (1.97)2.24 (2.81).5777 ICU0.20 (0.86)0.22 (0.99)0.16 (0.50).6824Estimated stay cost, dollars (±SD) Regular bed$4685.56 ($5066.44)$4511.90 ($4471.84)$5046.51 ($6155.93).5375 ICU bed$1008.24 ($4359.75)$1108.66 ($5008.50)$799.52 ($2561.01).6787Estimated procedure cost, dollars (±SD)$3929.27a ($3726.03)$1417.77a ($179.24)$9099.99 ($1566.65).0000Total cost excluding procedure (±SD)$5699.93 ($7958.46)$5628.97 ($8270.96)$5846.03 ($7349.98).8736Total cost including procedure (±SD)$9629.20a ($8820.08)$7046.74 a ($8299.06)$14,946.02 ($7420.43).0000an = n-1, one procedure excluded as it was converted from TCAR to CEA. Open table in a new tab