Cost-effectiveness of intraoperative imaging in carotid endarterectomy

OBJECTIVE: There has never been a large, randomized controlled trial to assess the impact of intraoperative imaging on the success of carotid endarterectomy (CEA). This comparison involves cost-effectiveness analysis. METHODS: We constructed a decision-analytic model to compare effectiveness and costs of intraoperative ultrasound (IUS) and completion angiography as adjuncts to CEA. Data on procedural mortality, morbidity, and costs were obtained from the English-language literature. The review included a total of 52 reports, encompassing more than 22,000 patients. The main components of costs were those of the monitoring interventions and the care of perioperative stroke. RESULTS: Mean perioperative outcome without completion imaging is approximately 96.7% of what it would be in the absence of perioperative stroke or death. IUS and completion angiography each result in approximately 2% improvement in expected outcome. Mean perioperative costs are $396.50 for IUS, $721.30 for no monitoring, and $840.90 for completion angiography. Because IUS is significantly more effective at detecting technical errors that would likely result in perioperative stroke than no imaging and is significantly less costly than angiography, this strategy dominates the other two (i.e., it provides greater effectiveness at lower cost). CONCLUSION: Although surgical complications are uncommon, IUS substantially lowers the rate of perioperative stroke and mortality and thus is significantly more cost-effective than either completion angiography or no operative imaging.