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Incremental Cost of Complications after Carotid Artery Stenting and Carotid Endarterectomy
Hanaa Dakour Aridi, MD, Besma Nejim, MBChB, MPH, Satinderjit Locham, MD, Husain Alshaikh, MD, Mahmoud B. Malas, MD,MHS, FACS,.
Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective(s): We have shown before that Carotid Endarterectomy (CEA) has a lower baseline cost compared to Carotid Artery Stenting (CAS).The aim of this study was to quantify the incremental cost associated with postoperative stroke, death and MI after CAS and CEA.
Methods: A retrospective analysis of Premier Research Database 2009-2015 (over 700 U.S. hospitals) was performed. Study outcomes included the rates of stroke, death and MI, and the incremental costs (in USD) associated with these complications. Multivariate logistic models and post estimation marginal effects were performed to account for confounding factors.
Results: Of 100,185 patients who met inclusion criteria, 14,150 (14.1%) underwent CAS.Mean age was 70.79.5 years.Most patients were males (58.3%), white (82.1%) and had Medicare Insurance (74.7%). Risk of stroke (2.6% vs. 1.4%,p<0.001),and death (1.4% vs.0.4%,p<0.001) was higher for CAS vs.CEA;however, there was no difference in risk of MI between the two procedures. In adjusted analysis,CAS was associated with 55% higher odds of stroke [aOR (95%CI): 1.55(1.36-1.77),p<0.001] and 2.6 folds' increase in the odds of in-hospital death [aOR: 2.60 (2.14-3.17),p<0.001] compared to CEA.The adjusted incremental costs associated with death and MI were similar between CEA and CAS regardless of symptomatic status. However, in asymptomatic patients, the adjusted cost associated with stroke was significantly higher after CEA compared to CAS by an estimated $2,000 ($7,581 vs.$5,568, p=0.02) (Table). Asymptomatic patients undergoing CEA had also a higher percentage increase from baseline cost associated with stroke (85.5% vs. 44.5%), death (91.0% vs. 69.6%) and MI (81.3% vs. 58.0%) compared to asymptomatic patients undergoing CAS, mainly because CEA has a lower baseline cost than CAS.
Conclusion: CEA is known to be a more cost-effective carotid intervention since it has less complications and a lower baseline cost compared to CAS. However, in asymptomatic patients, the adjusted incremental cost associated with stroke is significantly higher after CEA than CAS. This might be due to different severity and extent of stroke after the two procedures.These findings are important when considering long-term cost-effectiveness and quality improvement interventions.
Table - Comparison of Adjusted Incremental Cost (aIC) of each Complication between CEA and CAS Stratified with respect to Symptomatic Status

ASYMPTOMATIC
CASCEAMean Difference p-value
Baseline Cost12,502 [12,387-12,618]8,868 [8,836-8901]3,199 [3,079-3,319]<0.001
aIC (95%CI)aIC (95%CI)
Stroke5,568 [4,037-7,097]7,581[6,837-8,325]2,014 [315-3,712]0.02
MI7,255 [3,654-10,855]7,210 [6,244-8,175](-)45 [(-)3,771-3,681]0.98
Death8,704 [4,740-12,668]8,095 [6,330-9,861](-)609 [(-)4,946-3,729]0.78
Stroke & Death7,609 [506-14,712]8,547 [5,783-11,310]938 [(-)6,683-8,558]0.81
MI & Death12,142 [1,267-23,016]6,011 [1,835-10,186](-)6,131 [(-)17,779-5,517]0.30
SYMPTOMATIC
CASCEAMean Difference p-value
Baseline Cost17,348 [17,019-17,677]12,193 [12,076-12,310]3,980 [3,638-4,323)<0.001
aIC (95%CI)aIC (95%CI)
Stroke4,106 [425-7,787]4,229 [2,961-5,496]123 [(-)3,762-4,008]0.95
MI6,356 [382-12,329]7,936 [5,220-10,652]1,580 [(-)4,977-8,137]0.64
Death3,123[370-5,876]4,653 [1,873-7,433]1,530 [(-)2,374-5,434]0.44
Stroke & Death3,787 [(-)4,799-12,373]1,597 [(-)3,878-7,073](-)2,189 [(-)12,365-7,986]0.67
MI & Death249 [(-)24,170-24,667]3,259 [(-)2,605-9,124]3,011 [(-)22,101-28,122]0.81


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