A contemporary paradigm for value-based medicine in the management of carotid artery disease

Objectives To synthesize contemporary evidence on outcomes and cost-efficiency for best medical therapy (BMT), carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR) in carotid artery disease (CAD) through a value-based medicine (VBM) lens. Methods Narrative review of major guidelines (SVS 2022; ESVS 2023; AHA/ASA 2021), landmark trials and registries (e.g., CREST, CREST-2, ACST-2, VQI, ROADSTER-era series), and recent economic evaluations. Endpoints included peri-procedural safety, long-term ipsilateral stroke, health-related quality of life, and incremental cost-effectiveness ratios (ICERs). Results BMT remains the foundation of high-value care and has reduced annual ipsilateral-stroke risk for many asymptomatic patients to roughly 0.5-1%. Contemporary centers of excellence for CEA report 30-day combined stroke/death ∼1-2% for asymptomatic and