Perioperative Imaging Strategies for Carotid Endarterectomy: An Analysis of Morbidity and Cost-effectiveness in Symptomatic Patients

To assess the cost-effectiveness of four diagnostic strategies for the preoperative evaluation of symptomatic patients who are potential candidates for carotid endarterectomy (ie, 70% to 99% stenosis): (1) duplex sonography (DS), (2) magnetic resonance angiography (MRA), (3) contrast angiography (CA), and (4) the combination of DS and MRA supplemented by CA for disparate results. Cost-effectiveness analysis based largely on published clinical trial data. Sensitivities and specificities of noninvasive tests were estimated from 81 patients undergoing prospective evaluation with DS, MRA, and CA. Incremental cost per quality-adjusted year of life gained. For a hypothetical cohort of symptomatic patients undergoing evaluation for carotid endarterectomy, the combination of tests resulted in the greatest quality-adjusted life expectancy of the four options considered. After incorporating the costs of testing, surgery, and stroke, we found that neither the MRA nor the CA strategy was cost-effective. The combination of tests was more effective but more costly than DS, resulting in an additional cost of $22 400 per quality-adjusted year of life gained. For centers that do not have adequate MRA, CA resulted in an additional cost of $99 200 per quality-adjusted year of life saved compared with DS. Our results suggest that for the preoperative detection of a 70% to 99% carotid stenosis, the combination of DS and MRA, supplemented by CA for disparate results, is associated with the lowest long-term morbidity and mortality and has a favorable cost-effectiveness ratio. The combination of tests, or DS alone when MRA is not available, could potentially replace the current practice of using CA alone in the preoperative evaluation of patients with symptomatic carotid stenosis.