(PC110) Carotid Revascularization Modality Does Not Affect Hospital Contribution Margin in High-Risk Patients

Objectives: Prior clinical reports suggest that trans-carotid artery revascularization (TCAR) is less cost-effective than both carotid endarterectomy (CEA) and trans-femoral carotid artery stenting (TF-CAS). The hypothesis of this study is that high-risk patients may benefit from minimal access techniques when practiced at a comprehensive center within a shared decision-making framework. The purpose of this study is to describe observed fiscal outcomes of a high-risk subset of patients undergoing carotid revascularization.

Methods: Demographic and perioperative data were acquired for previously published high-risk criteria for TCAR, CEA, or TF-CAS (excluding concurrent intracranial interventions) procedures from January, 2016 to July, 2024. Hospital-level financial data were obtained. Primary outcomes included total hospital encounter variable cost, reimbursement, and contribution margin. Secondary outcomes included perioperative characteristics and outcomes including stroke-death rate.

Results: There were 342 patients in the TCAR group, 362 in the CEA group, and 330 in the TF-CAS group. There were no significant differences in age, sex, diabetes, or dialysis status although TF-CAS patients were significantly more likely to be non-white (10.0%, p = 0.032). TCAR patients had more comorbid conditions including a history of CABG, PCI, and CAD. Re-stenotic lesions were a more common indication in TCAR patients compared to CEA and TF-CAS. The 30-day stroke-death rates for symptomatic TCAR, CEA, and TF-CAS were 2.0%, 1.4%, and 0.7% (p = 0.506), respectively; for asymptomatic cases they were 0.0%, 0.9%, and 0.0% (p = 0.356), respectively. There were no significant differences in 1-year stroke-death outcomes for symptomatic (p = 0.449) and asymptomatic (p = 0.981) cases (Table I). Financial data demonstrated cost superiority in the CEA group. However, increased reimbursement in the TCAR and TF-CAS groups leads to equivalent contribution margins between CEA, TCAR, and TF-CAS ($5497.52 ± 906.66, $3826.91 ± 943.42, and $4472.28 ± 849.12, respectively; p = 0.447 and 0.330, Table II). There were no differences in financial outcomes when adjusted for public versus private insurance status.

Conclusions: This is the largest single hospital system series reported to date to examine financial outcomes of carotid revascularization including TCAR. These findings demonstrate that there are equivalent hospital financial margins in high-risk patients undergoing carotid revascularization at a high-volume institution with high fidelity surgeons despite higher variable costs of both TCAR and TF-CAS compared with CEA. This series illustrates that comprehensive and patient-specific application of revascularization techniques can optimize clinically and fiscally sustainable outcomes.