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

ABSTRACT Objectives 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 <6% for symptomatic disease. Randomized trials in asymptomatic patients comparing TF-CAS with CEA report non-inferiority for primary composite endpoints, with a slightly higher early non-disabling stroke after stenting. Carotid stenting plus intensive medical therapy was associated with a lower 4-year primary composite event rate versus intensive medical therapy alone, whereas intensive medical therapy plus CEA did not significantly differ from intensive medical therapy alone over the same time horizon, reflecting carotid-attributable risk rather than total stroke risk. Although no randomized head-to-head trials compare TCAR with CEA or TF-CAS, registry-based comparisons generally report higher periprocedural stroke with TF-CAS relative to CEA and TCAR, and broadly comparable short-term outcomes between TCAR and CEA in selected cohorts. Emerging patient-level and lesion-level risk models and integration of Artificial Intelligence (AI) may support individualized selection across treatment options. Higher device and supply costs make TCAR's cost-effectiveness conditional on case mix and pathway efficiency. Multidisciplinary, guideline-driven pathways and real-time audit improve efficiencies, reducing intra- and periprocedural resource use. 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.