Cost-Utility Analysis of Carotid Artery Angioplasty and Carotid Endarterectomy in Iran
Abstract
Background: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are two standard methods for the prevention and treatment of cerebrovascular accidents.
Objectives: This study compared these two methods using an economic evaluation analysis.
Methods: One hundred patients with carotid occlusive disease at Razi Hospital in Rasht, Iran, were analyzed in a retrospective cost-utility study using the SF-12 Questionnaire to calculate quality-adjusted life year (QALY) and costs from a societal perspective. This study employed Monte Carlo simulation and sensitivity analysis for data analysis.
Results: Of the 100 patients, 61 were male, and 64 underwent CEA treatment. The incremental cost-effectiveness ratio (ICER) of CAS versus CEA was US$ 213.6 (± 111.2). The ICER increased to US$ 1625.6 when governmental currency exchange subsidies were excluded from the cost calculations of the two methods.
Conclusions: Both the costs and QALY of CAS are higher than those of CEA. The CAS is cost-effective when the preferred currency rate is applied to medical equipment pricing [compared to the willingness to pay (WTP) threshold of US$ 1431.85]. However, it is not cost-effective when government subsidies are removed.
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5. Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Dajles A, Garg A, et al. Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2022;11(2):e022335. [PubMed ID:35023353]. [PubMed Central ID:PMC9238531]. https://doi. org/10.1161/JAHA.121.022335.
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7. Aghajanzadeh M, Ashoobi MT, Hemmati H, Samidoust P, Delshad MSE, Pourahmadi Y. Intrabiliary and abdominal rupture of hepatic hydatid cyst leading to biliary obstruction, cholangitis, pancreatitis, peritonitis and septicemia: A case report. J Med Case Rep. 2021;15(1):311. [PubMed ID:34049575]. [PubMed Central ID:PMC8164221]. https://doi.org/10.1186/s13256-021-02822-5.
8. Eckstein H-H, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis. Deutsches Ärzteblatt international. 2020;117(47). https://doi.org/10.3238/arztebl.2020.0801.
9. Cebula H, Kurbanov A, Zimmer LA, Poczos P, Leach JL, De Battista JC, et al. Endoscopic, endonasal variability in the anatomy of the internal carotid artery. World Neurosurg. 2014;82(6):e759-64. [PubMed ID:25238676]. https://doi.org/10.1016/j.wneu.2014.09.021.
10. Olyaaeemanesh A, Jaafaripooyan E, Abdollahiasl A, Davari M, Mousavi SM, Delpasand M. Pharmaceutical subsidy policy in Iran: a qualitative stakeholder analysis. Health Res Policy Syst. 2021;19(1):150. [PubMed ID:34949207]. [PubMed Central ID:PMC8697451]. https://doi.org/10.1186/s12961-021-00762-6.
11. Shabanzadeh Khoshrody M, Gilanpour O, Javdan E, rafaati M. [The Effect of Preferred Currency Subsidies Policy on Food Consumption in Urban Areas of Iran]. Economic Res. 2022;22(3):129-55. Persian.
12. Young KC, Holloway RG, Burgin WS, Benesch CG. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis. 2010;19(5):404-9. [PubMed ID:20816349]. [PubMed Central ID:PMC2936727]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.08.003.
13. Gurm HS, Nallamothu BK, Yadav J. Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis. Eur Heart J. 2008;29(1):113-9. [PubMed ID:17881346]. https://doi.org/10.1093/eurheartj/ehm362.
14. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC Public Health. 2009;9:341. [PubMed ID:19758427]. [PubMed Central ID:PMC2749829]. https://doi.org/10.1186/1471-2458-9-341.
15. Moradi N, Rashidian A, Nosratnejad S, Olyaeemanesh A, Zanganeh M, Zarei L. Willingness to pay for one quality adjusted life year in Iran. Cost Eff Resour Alloc. 2019;17:4. [PubMed ID:30867654].
[PubMed Central ID:PMC6396529]. https://doi.org/10.1186/s12962-019-0172-9.
16. Brott TG, Hobson RW, 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23. [PubMed ID:20505173]. [PubMed Central ID:PMC2932446]. https://doi.org/10.1056/NEJMoa0912321.
17. Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev. 2012(9):CD000515. [PubMed ID:22972047]. https://doi.org/10.1002/14651858.CD000515.pub4.
18. Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and longterm outcomes. Stroke. 2011;42(3):687-92. [PubMed ID:21233476]. https://doi.org/10.1161/STROKEAHA.110.606079.
19. de Borst GJ, Naylor AR. In the End, It All Comes Down to the Beginning! Eur J Vasc Endovasc Surg. 2015;50(3):271-2. [PubMed ID:25957820]. https://doi.org/10.1016/j.ejvs.2015.04.013.
20. Mahoney EM, Greenberg D, Lavelle TA, Natarajan A, Berezin R, Ishak KJ, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: Results from the SAPPHIRE trial. Catheter Cardiovasc Interv. 2011;77(4):463-72. [PubMed ID:21351220]. https://doi.org/10.1002/ ccd.22869.
21. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD, 2nd, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: Results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2012;43(9):2408-16. [PubMed ID:22821614]. [PubMed Central ID:PMC3555501]. https://doi.org/10.1161/STROKEAHA.112.661355.
22. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol.2001;38(6):1589-95. [PubMed ID:11704367]. https://doi.org/10.1016/s0735-1097(01)01595-9.
23. Phan TG, Beare RJ, Jolley D, Das G, Ren M, Wong K, et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke. 2012;43(6):1596-601. [PubMed ID:22511010]. https://doi.org/10.1161/STROKEAHA.111.645499.
24. Arboix A. Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke. World J Clin Cases. 2015;3(5):418-29. [PubMed ID:25984516]. [PubMed Central ID:PMC4419105]. https://doi.org/10.12998/wjcc.v3.i5.418.
25. Sternbergh WC, Crenshaw GD, Bazan HA, Smith TA. Carotid endarterectomy is more cost-effective than carotid artery stenting. J Vasc Surg. 2012;55(6):1623-8. [PubMed ID:22459744]. https://doi.org/10.1016/j.jvs.2011.12.045.
26. Morris S, Patel NV, Dobson J, Featherstone RL, Richards T, Luengo-Fernandez R, et al. Cost-utility analysis of stenting versus endarterectomy in the International Carotid Stenting Study. Int J Stroke. 2016;11(4):446-53. [PubMed ID:26880056]. [PubMed Central ID:PMC5341766]. https://doi.org/10.1177/1747493016632237.
27. Gray WA, White HJ, Jr., Barrett DM, Chandran G, Turner R, Reisman M. Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies. Stroke. 2002;33(4):1063-70. [PubMed ID:11935062]. https://doi.org/10.1161/hs0402.105304.
28. Ecker RD, Brown RD, Jr., Nichols DA, McClelland RL, Reinalda MS, Piepgras DG, et al. Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy. J Neurosurg. 2004;101(6):904-7. [PubMed ID:15597748]. https://doi.org/10.3171/jns.2004.101.6.0904.
29. Kilaru S, Korn P, Kasirajan K, Lee TY, Beavers FP, Lyon RT, et al. Is carotid angioplasty and stenting more cost effective than carotid endarterectomy? J Vasc Surg. 2003;37(2):331-9. [PubMed ID:12563203]. https://doi.org/10.1067/mva.2003.124.
30. Rothwell PM, Mehta Z, Howard SC, Gutnikov SA, Warlow CP. Treating individuals 3: from subgroups to individuals: General principles and the example of carotid endarterectomy. Lancet. 2005;365(9455):256-65. [PubMed ID:15652609]. https://doi.org/10.1016/S0140-6736(05)17746-0.
31. Spence JD, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67(2):180-6. [PubMed ID:20008646]. https://doi.org/10.1001/archneurol.2009.289.
32. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke. 2009;40(10):e573-83. [PubMed ID:19696421]. https://doi.org/10.1161/STROKEAHA.109.556068.
stents in coronary artery disease: a meta-analysis. Eur Heart J. 2006;27(23):2784-814. [PubMed ID:17020889]. https://doi. org/10.1093/eurheartj/ehl282.
2. Dolatshahi Z, Mezginejad F, Nargesi S, Saliminejad M. Cost-Effectiveness of Endovascular Aneurysm Repair Versus Open Surgical Repair for Ruptured Abdominal Aortic Aneurysms: A Systematic Review. Iran J Radiol. 2021;18(3). https://doi.org/10.5812/iranjradiol.109932.
3. Janssen MP, de Borst GJ, Mali WPTM, Kappelle LJ, Moll FL, Acker-staff RGA, et al. Carotid Stenting versus Carotid Endarterectomy: Evidence Basis and Cost Implications. J Vascular Surg. 2008;48(3). https://doi.org/10.1016/j.jvs.2008.07.031.
4. Borhani-Haghighi A, Hooshmandi E, Zahediasl F, Molavi Vardanjani H, Rezaei M, Rahimi-Jaberi A, et al. Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients. J Neuroimaging. 2022;32(6):1161-9. [PubMed ID:35969379]. https://doi.org/10.1111/jon.13036.
5. Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Dajles A, Garg A, et al. Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2022;11(2):e022335. [PubMed ID:35023353]. [PubMed Central ID:PMC9238531]. https://doi. org/10.1161/JAHA.121.022335.
6. Wang J, Bai X, Wang T, Dmytriw AA, Patel AB, Jiao L. Carotid Stenting Versus Endarterectomy for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Stroke. 2022;53(10):3047-54. [PubMed ID:35730457]. https://doi.org/10.1161/STROKEAHA.122.038994.
7. Aghajanzadeh M, Ashoobi MT, Hemmati H, Samidoust P, Delshad MSE, Pourahmadi Y. Intrabiliary and abdominal rupture of hepatic hydatid cyst leading to biliary obstruction, cholangitis, pancreatitis, peritonitis and septicemia: A case report. J Med Case Rep. 2021;15(1):311. [PubMed ID:34049575]. [PubMed Central ID:PMC8164221]. https://doi.org/10.1186/s13256-021-02822-5.
8. Eckstein H-H, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis. Deutsches Ärzteblatt international. 2020;117(47). https://doi.org/10.3238/arztebl.2020.0801.
9. Cebula H, Kurbanov A, Zimmer LA, Poczos P, Leach JL, De Battista JC, et al. Endoscopic, endonasal variability in the anatomy of the internal carotid artery. World Neurosurg. 2014;82(6):e759-64. [PubMed ID:25238676]. https://doi.org/10.1016/j.wneu.2014.09.021.
10. Olyaaeemanesh A, Jaafaripooyan E, Abdollahiasl A, Davari M, Mousavi SM, Delpasand M. Pharmaceutical subsidy policy in Iran: a qualitative stakeholder analysis. Health Res Policy Syst. 2021;19(1):150. [PubMed ID:34949207]. [PubMed Central ID:PMC8697451]. https://doi.org/10.1186/s12961-021-00762-6.
11. Shabanzadeh Khoshrody M, Gilanpour O, Javdan E, rafaati M. [The Effect of Preferred Currency Subsidies Policy on Food Consumption in Urban Areas of Iran]. Economic Res. 2022;22(3):129-55. Persian.
12. Young KC, Holloway RG, Burgin WS, Benesch CG. A cost-effectiveness analysis of carotid artery stenting compared with endarterectomy. J Stroke Cerebrovasc Dis. 2010;19(5):404-9. [PubMed ID:20816349]. [PubMed Central ID:PMC2936727]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.08.003.
13. Gurm HS, Nallamothu BK, Yadav J. Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis. Eur Heart J. 2008;29(1):113-9. [PubMed ID:17881346]. https://doi.org/10.1093/eurheartj/ehm362.
14. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC Public Health. 2009;9:341. [PubMed ID:19758427]. [PubMed Central ID:PMC2749829]. https://doi.org/10.1186/1471-2458-9-341.
15. Moradi N, Rashidian A, Nosratnejad S, Olyaeemanesh A, Zanganeh M, Zarei L. Willingness to pay for one quality adjusted life year in Iran. Cost Eff Resour Alloc. 2019;17:4. [PubMed ID:30867654].
[PubMed Central ID:PMC6396529]. https://doi.org/10.1186/s12962-019-0172-9.
16. Brott TG, Hobson RW, 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23. [PubMed ID:20505173]. [PubMed Central ID:PMC2932446]. https://doi.org/10.1056/NEJMoa0912321.
17. Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev. 2012(9):CD000515. [PubMed ID:22972047]. https://doi.org/10.1002/14651858.CD000515.pub4.
18. Economopoulos KP, Sergentanis TN, Tsivgoulis G, Mariolis AD, Stefanadis C. Carotid artery stenting versus carotid endarterectomy: a comprehensive meta-analysis of short-term and longterm outcomes. Stroke. 2011;42(3):687-92. [PubMed ID:21233476]. https://doi.org/10.1161/STROKEAHA.110.606079.
19. de Borst GJ, Naylor AR. In the End, It All Comes Down to the Beginning! Eur J Vasc Endovasc Surg. 2015;50(3):271-2. [PubMed ID:25957820]. https://doi.org/10.1016/j.ejvs.2015.04.013.
20. Mahoney EM, Greenberg D, Lavelle TA, Natarajan A, Berezin R, Ishak KJ, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at increased surgical risk: Results from the SAPPHIRE trial. Catheter Cardiovasc Interv. 2011;77(4):463-72. [PubMed ID:21351220]. https://doi.org/10.1002/ ccd.22869.
21. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD, 2nd, et al. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: Results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2012;43(9):2408-16. [PubMed ID:22821614]. [PubMed Central ID:PMC3555501]. https://doi.org/10.1161/STROKEAHA.112.661355.
22. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol.2001;38(6):1589-95. [PubMed ID:11704367]. https://doi.org/10.1016/s0735-1097(01)01595-9.
23. Phan TG, Beare RJ, Jolley D, Das G, Ren M, Wong K, et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke. 2012;43(6):1596-601. [PubMed ID:22511010]. https://doi.org/10.1161/STROKEAHA.111.645499.
24. Arboix A. Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke. World J Clin Cases. 2015;3(5):418-29. [PubMed ID:25984516]. [PubMed Central ID:PMC4419105]. https://doi.org/10.12998/wjcc.v3.i5.418.
25. Sternbergh WC, Crenshaw GD, Bazan HA, Smith TA. Carotid endarterectomy is more cost-effective than carotid artery stenting. J Vasc Surg. 2012;55(6):1623-8. [PubMed ID:22459744]. https://doi.org/10.1016/j.jvs.2011.12.045.
26. Morris S, Patel NV, Dobson J, Featherstone RL, Richards T, Luengo-Fernandez R, et al. Cost-utility analysis of stenting versus endarterectomy in the International Carotid Stenting Study. Int J Stroke. 2016;11(4):446-53. [PubMed ID:26880056]. [PubMed Central ID:PMC5341766]. https://doi.org/10.1177/1747493016632237.
27. Gray WA, White HJ, Jr., Barrett DM, Chandran G, Turner R, Reisman M. Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies. Stroke. 2002;33(4):1063-70. [PubMed ID:11935062]. https://doi.org/10.1161/hs0402.105304.
28. Ecker RD, Brown RD, Jr., Nichols DA, McClelland RL, Reinalda MS, Piepgras DG, et al. Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy. J Neurosurg. 2004;101(6):904-7. [PubMed ID:15597748]. https://doi.org/10.3171/jns.2004.101.6.0904.
29. Kilaru S, Korn P, Kasirajan K, Lee TY, Beavers FP, Lyon RT, et al. Is carotid angioplasty and stenting more cost effective than carotid endarterectomy? J Vasc Surg. 2003;37(2):331-9. [PubMed ID:12563203]. https://doi.org/10.1067/mva.2003.124.
30. Rothwell PM, Mehta Z, Howard SC, Gutnikov SA, Warlow CP. Treating individuals 3: from subgroups to individuals: General principles and the example of carotid endarterectomy. Lancet. 2005;365(9455):256-65. [PubMed ID:15652609]. https://doi.org/10.1016/S0140-6736(05)17746-0.
31. Spence JD, Coates V, Li H, Tamayo A, Munoz C, Hackam DG, et al. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67(2):180-6. [PubMed ID:20008646]. https://doi.org/10.1001/archneurol.2009.289.
32. Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke. 2009;40(10):e573-83. [PubMed ID:19696421]. https://doi.org/10.1161/STROKEAHA.109.556068.
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| Issue | Vol 9 No 2 (2025) | |
| Section | Articles | |
| DOI | https://doi.org/10.18502/htaa.v9i2.18715 | |
| Keywords | ||
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How to Cite
1.
Ashoobi MT, Zahedfar S, Hemmati H, Homaie Rad E. Cost-Utility Analysis of Carotid Artery Angioplasty and Carotid Endarterectomy in Iran. Health Tech Ass Act. 2025;9(2).
