Hicks Caitlin W, Veith Frank J
Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD.
New York University Medical Center NY, The Cleveland Clinic, Cleveland, OH.
Ann Vasc Surg. 2025 Apr;113:337-345. doi: 10.1016/j.avsg.2024.09.037. Epub 2024 Oct 5.
In October 2023, the Centers for Medicare & Medicaid Services agreed to revisit its national coverage determination (NCD) for carotid artery stenting (CAS). We provide an overview of the arguments presented in favor and against NCD expansion, and discuss the likely ramifications on patient care and outcomes in the future.
We completed a narrative review of the arguments presented in favor and against NCD expansion.
Arguments presented in favor of the CAS NCD expansion predominantly focused on the outcomes of 4 large multicenter randomized controlled trials published between 2010 and 2021 that reported similar outcomes for composite end points between patients undergoing CAS and carotid endarterectomy. The main arguments against expanding the CAS NCD centered around higher patient stroke risks with CAS, increasing health-care costs, premature decision-making, and the lack of a validated shared decision-making tool that can be readily applied to carotid revascularization.
By expanding the indications for CAS to asymptomatic and standard-risk patients, they will be exposed to excess and unnecessary risks without any evident benefits, potentially leading to widespread adoption of a procedure driven by financial incentives rather than genuine patient benefits.
2023年10月，医疗保险和医疗补助服务中心同意重新审视其关于颈动脉支架置入术（CAS）的全国覆盖范围判定（NCD）。我们概述了支持和反对扩大NCD的论点，并讨论了其对未来患者护理和治疗结果可能产生的影响。
我们对支持和反对扩大NCD的论点进行了叙述性综述。
支持扩大CAS的NCD的论点主要集中在2010年至2021年间发表的4项大型多中心随机对照试验的结果上，这些试验报告了接受CAS和颈动脉内膜切除术的患者在复合终点方面的相似结果。反对扩大CAS的NCD的主要论点集中在CAS患者中风风险较高、医疗成本增加、决策过早以及缺乏可直接应用于颈动脉血运重建的经过验证的共同决策工具。
通过将CAS的适应症扩大到无症状和标准风险患者，他们将面临过多和不必要的风险，而没有任何明显益处，这可能导致一种由经济激励而非真正患者受益驱动的手术被广泛采用。
