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Review
. 2025 Oct;16(5):1874-1883.
doi: 10.1007/s12975-025-01347-z. Epub 2025 Apr 11.

Cost-Effectiveness of Carotid Endarterectomy vs. Carotid Stenting: a Systematic Review and Meta-Analysis

Yash Akkara  1 , Joshua J Hon  1 , Mahathir Ahmed  1 , Basel Musmar  2 , Joanna Roy  2 , Stavropoula Tjoumakaris  2 , Michael Reid Gooch  2 , Robert H Rosenwasser  2 , Pascal Jabbour  3
Affiliations
Review

Cost-Effectiveness of Carotid Endarterectomy vs. Carotid Stenting: a Systematic Review and Meta-Analysis

Yash Akkara et al. Transl Stroke Res. 2025 Oct.

Abstract

Introduction: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are gold-standard treatments of carotid artery stenosis. This study aims to identify the cost-effectiveness of CEA vs CAS.

Methods: Studies were screened through PubMed, MEDLINE, and Embase using PRISMA guidelines, and required ≥ 20 participants who were ≥ 16 years, alongside costs at 1-year postoperatively. The Shapiro-Wilk test, independent sample t-tests, ANOVA, and Spearman's R were used, with costs adjusted to 2024. A random-effects model was used to compare cost-effectiveness. Bias assessment was according to the Cochrane Risk of Bias 2.0 tool and the Newcastle-Ottawa Scale.

Results: 7 studies were included, with a sample of 6493 participants (3418 M, 3075 F). 2932 and 3511 participants underwent CEA and CAS respectively. CEA reported a significantly longer mean length of procedure (191.92 vs. 77.5 min, p < 0.0001) and length of stay (3.13 vs. 2.60 days, p < 0.0001) vs. CAS. The mean adjusted cost of CEA and CAS were $18156.60 (6466) and $17711.01 (5511) respectively. Studies reported lower risks of stroke (2.12% vs. 3.65%, p < 0.001), higher risks of myocardial infarctions (1.70% vs. 1.42%, p < 0.01), and higher risks of other complications for CEA vs. CAS respectively. The expected 1-year cost of CEA was marginally lower than CAS ($21264.03 vs. $21433.14, p < 0.05). The cost-effectiveness of CEA was marginally better than CAS (ratio = 1.019, 95% CI [1.017, 1.020)].

Conclusions: CEA provides marginally improved cost-effectiveness over CAS, providing long-term cost benefits to centers with large surgical volumes. However, shorter procedural times and inpatient stays with CAS may improve overall productivity. Cost should hence not be a deciding factor when choosing between CEA and CAS.

Keywords: Carotid Endarterectomy; Carotid Stenosis; Carotid Stenting; Cost; Cost-Effectiveness; Interventional Neuroradiology; Neurosurgery.

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Conflict of interest statement

Declarations. Ethical Approval: This study is not subject to ethical approval, with all work exclusively building on the existing literature. Disclosure: The authors have no relevant financial or non-financial interests to disclose. Statement on Publication: This work is not under consideration for publication elsewhere, with the work approved by all authors. There have been no prior submissions or previous reports, or preprints. Competing Interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA diagram of included studies
Fig. 2
Fig. 2
Risk of bias analysis of included studies
Fig. 3
Fig. 3
Forest Plot of Odds of Cost-Effectiveness by QALY/$100,000 of CEA vs. CAS by study
See this image and copyright information in PMC

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