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Single Center Cost Analysis Comparing High-Risk Carotid Endarterectomy and Transcarotid Artery Revascularization (TCAR)
Senthil Jayarajan, MD MPH, Benjamin Szpila, MD, Jeffrey Jim, MD.
Washington University, St Louis, MO, USA.

OBJECTIVES:
Transcarotid artery revascularization (TCAR) using reversal of flow has been shown to be a safe and effective means of treating carotid artery stenosis. However, no real-world analysis of the cost of using TCAR instead of CEA for high risk carotid stenosis has been performed.
METHODS: A retrospective, single-center analysis was performed comparing demographics, complications, and costs for patients with Medicare defined high-risk characteristics undergoing TCAR versus carotid endarterectomy (CEA) from January 2014 to June 2017. Direct costs were obtained from hospital finance department. Costs were adjusted to 2017 dollars and are reported as median values.
RESULTS: 44 patients underwent high-risk CEA and 46 patients underwent TCAR. There were no significant differences in overall demographics as well as comorbidities. No difference with respect to symptomatic status (CEA: 36.4% vs. TCAR: 45.7%, p=0.496) or treatment of restenosis (CEA: 11.4% vs. TCAR 13%, p=1.0) was noted. Length of stay was also not different (CEA: 3.4 days vs. TCAR: 2.9 days, p=0.65). The 30-day composite outcome of stroke, MI, and death was similar between the groups (CEA: 4.6% vs. TCAR: 2.2%, p=0.612). TCAR had lower surgery time(CEA: 137 mins vs. 83 mins, p<0.001). Overall median hospital stay costs for CEA and TCAR was $5093.62 and $10490.18 (p<0.001) respectively. The median OR (operating room) costs for CEA ($2705.24) was lower than TCAR ($8974.65), with most of the cost difference explained by OR supplies (CEA: $780 vs. TCAR: $6258); p<0.001. All other major sources of hospital costs including intensive care unit, pharmacy, labs, radiology, room and board and ancillary costs were similar between the groups.
CONCLUSIONS: Compared to CEA, total direct costs are higher for TCAR, with most related to OR supply costs. However, based on the 2017 Medicare fee schedule, the higher reimbursement for carotid stenting nearly negates this difference. Additional studies evaluating the financial impact of shorter surgery time as well as clinical outcomes are necessary to evaluate the cost-effectiveness between these two procedures.


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