CREST: Similar Cost Effectiveness for Carotid Stenting, Surgery

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Money should not be a factor when choosing between carotid artery stenting (CAS) and carotid endarterectomy (CEA), according to a cost-effectiveness analysis from the CREST trial showing only trivial differences in cost and quality-adjusted life expectancy between the 2 procedures over a projected 10-year span. The findings were published online July 19, 2012, ahead of print in Stroke.

The main Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) randomized 2,502 patients with symptomatic or asymptomatic carotid stenosis to CEA or CAS. Overall, there was no difference between the 2 groups in the estimated 4-year rates of the primary endpoint (composite of periprocedural stroke, MI, or death, or the incidence of ipsilateral stroke ≤ 4 years). However, stenting carried a higher risk of stroke and surgery carried a higher risk of MI.

For the cost-effectiveness analysis, CREST investigators led by David J. Cohen, MD, MSc, of Saint Luke’s Mid America Heart Institute (Kansas City, MO), estimated costs for all trial participants over the first year of follow-up using a combination of resource use data and hospital billing records. The researchers also projected 10-year costs and quality-adjusted life expectancy for the CAS and CEA groups.

Minimal Differences Seen

A mean of 1.01 stents and 0.95 embolic protection devices were used in the CAS arm, adding up to total device-related costs of $4,510 per patient. Although operating room costs (including overhead, depreciation, supplies, and nonphysician personnel) were substantially higher for CEA, total procedural costs were higher with CAS when device-related costs were factored into the analysis. Physician fees were higher with CEA, a difference mainly attributable to anesthesiology, as were postprocedural hospital costs, due in part to a longer mean duration of stay (3.0 days with CEA vs. 2.6 days with CAS; P = 0.002; table 1).

Table 1. Procedural and Postprocedural Cost Differences




P Value

Total Procedural Costs



< 0.001

Physician Fees



< 0.001

Postprocedural Hospital Costs




Total index hospitalization costs were similar for the CAS and CEA groups ($15,055 vs. $14,816; mean difference, $239/patient; P = 0.185). Neither follow-up costs after discharge nor total 1-year costs differed significantly.

Overall rates of hospitalization for repeat carotid revascularization (CAS or CEA) did not differ significantly between the 2 groups. As a result, mean follow-up costs did not differ significantly ($1,321 for CAS vs. $1,293 for CEA; P = 0.441).

Based on the observed 1-year trial results alone, CAS was associated with a small increase in cost ($267) and a small decrease in quality-adjusted life years (0.005), rendering CEA an economically dominant therapy (ie, associated with both lower cost and greater effectiveness than CAS) in the short term. In addition, for an overall population similar to that enrolled in CREST (mean age, 69 years; 53% symptomatic), a model projected that over 10 years CEA would be an economically dominant strategy with net cost savings of $524 and an increase in quality-adjusted life expectancy of 0.008 years. However, probabilistic sensitivity analysis demonstrated considerable uncertainty in the long-term results, with unstable incremental cost-effectiveness ratios.

Cost Not a Big Issue

“These findings suggest that for patients similar to those enrolled in the CREST trial, there is little reason to strongly prefer either CAS or CEA on economic grounds and that other factors such as individual patient preferences and center-specific outcomes should be considered when choosing between these 2 approaches to carotid revascularization,” the study authors write.

The investigators acknowledge that previous single-center cost studies “have consistently shown that procedural costs are higher with CAS than with CEA, due almost entirely to the cost of disposable devices (eg, stents, embolic protection devices).” They also point out that the only other multicenter study to-date comparing costs for the 2 procedures used data from the National Inpatient Sample to estimate hospital costs and found that they were nearly $5,000 higher per patient with CAS than CEA, a difference that was explained at least in part by much higher rates of comorbidities and complications among CAS patients. But Dr. Cohen and colleagues say they believe the subanalysis from CREST is more precise because it incorporates both resource-based costs and department-specific cost-to-charge ratios.

Data Could Signal a ‘Tipping Point’

“The beauty of this paper is it shows us that the upfront costs of the disposable supplies associated with carotid stenting accounts for the difference at 1 year,” said Christopher J. White, MD, of the Ochsner Heart and Vascular Institute (New Orleans, LA), in a telephone interview with TCTMD. “But over time, the difference becomes narrower so that at the end of the day it’s not a big enough difference to make you choose one procedure over the other.”

According to Dr. White, having data from the randomized CREST trial is a “welcome addition” to the literature. “The hope is very high that these kinds of data will be a tipping point because we already have the efficacy data, we have the FDA approval, we have a guideline stating that there should be room for choice and now we have the cost data,” Dr. White observed. “Unfortunately, there are still things conspiring to limit our patients’ choice.”

The main ‘thing’ standing in the way: the Centers for Medicare and Medicaid Services (CMS). Many interventionalists, including Dr. White, he said, feel the agency is being unreasonable in demanding more and more data to determine the proper role for CAS.

“What more could you want?” Dr. White asked. “[CMS’s] argument that they don’t have enough evidence doesn’t hold up anymore. The burden and weight of evidence is accumulating, and it’s becoming harder and harder for CMS to hide from it. No one is saying stenting should be the primary choice, or that physicians should steer patients to it, but the overwhelming evidence shows that the choice between the 2 procedures is justified because there is equipoise.”


Vilain KR, Magnuson EA, Li H, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: Results from the carotid revascularization endarterectomy versus stenting trial (CREST). Stroke. 2012:Epub ahead of print.



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  • Dr. Cohen reports receiving research grants from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic and consulting fees from Abbott Vascular, Cordis and Medtronic.
  • Dr. White reports no relevant conflicts of interest.