Carotid revascularization modality does not affect hospital contribution margin in high-risk patients

Objective 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 in accordance with previously published high-risk criteria for TCAR, CEA, and TF-CAS (excluding concurrent intracranial interventions) procedures from January 2016 to July 2024. Patient-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 was a total of 362 patients in the CEA group, 342 in the TCAR group, and 330 in the TF-CAS group with 228, 341, and 306 patients' financial data available for analysis, respectively. 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. There were no differences in the 30-day stroke-death rates, 1-year stroke-death rates, or contribution margins even after adjusting for insurance type between CEA, TCAR, and TF-CAS. There were no differences in financial outcomes when adjusted for public versus private insurance status. Conclusion This is one of 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.