Value based care in vascular disease-Carotid stenosis

A Value-Based, Personalized Approach to Carotid Artery Disease

At Cleveland Clinic’s Heart & Vascular Institute in Cleveland OHIO. value-based care means delivering the right treatment to the right patient at the right time—not simply performing a procedure because it is available. In the vascular surgery department at Cleveland Clinic particularly in the treatment of carotid artery stenosis, this approach requires careful attention to each patient’s anatomy, medical conditions, life expectancy, and personal goals. Together with my colleague Dr. Daniel Raskin & Sean Lyden, I have written about the importance of tailoring care to maximize benefit, minimize harm, and improve long-term outcomes.

Carotid artery disease is a common cause of stroke, but not every patient benefits from the same treatment. Some patients have narrowing that is severe but stable, others have symptoms such as transient weakness or speech difficulty, and some have anatomy that makes intervention higher or lower risk. A value-based approach begins with understanding the whole patient—their vascular anatomy, heart health, kidney function, age, diabetes status, and overall surgical risk—before recommending medical therapy, surgery, or stenting.

Importantly, modern medical therapy for cerebrovascular disease has improved dramatically. Contemporary data from the CREST trial and other studies show that optimized medical management—including cholesterol-lowering therapy, blood pressure control, antiplatelet therapy, smoking cessation, and lifestyle modification—has a very low annual stroke risk, approximately 1.3-1.7% in selected patients. For many individuals, especially those without symptoms, medical therapy alone may be the most appropriate and highest-value option.

For other patients, however, intervention provides meaningful stroke risk reduction. Carotid endarterectomy and carotid artery stenting remain powerful tools when used selectively and performed well. The value-based question is not “Can we intervene?” but rather “Will this intervention improve this patient’s outcome compared with medical therapy alone?” The answer depends on careful imaging, accurate risk stratification, and thoughtful discussion with the patient.

Experience matters. Outcomes for carotid procedures vary significantly by operator and institution. Over more than 20 years performing carotid endarterectomy, my personal perioperative stroke rate has been less than 0.5%, well below national benchmarks of 2% and the 1.7% observed in the recent CREST 2 data. Achieving this level of safety requires meticulous technique, appropriate patient selection, and a team-based environment that prioritizes quality, measurement, and continuous improvement.

Call to Action:
If you or a loved one has carotid artery disease, seek care from a provider and health system that practice personalized, value-based vascular medicine. Ask about all options—medical therapy, surgery, and stenting—and how the recommendation is tailored to your specific anatomy and health profile. Most importantly, choose a team with deep experience and documented outcomes in carotid endarterectomy and carotid stenting. The goal is not simply to treat an artery, but to prevent stroke, preserve function, and deliver lasting value to each patient.

Key Publications by Raskin & Kirksey

1.      Raskin D, Partovi S, Khan A, Lyden SP, Kirksey L.
A Contemporary Paradigm for Value-Based Medicine in Vascular Care: Challenges and Opportunities.
Annals of Vascular Surgery (2025).
This review articulates a comprehensive framework for transitioning vascular care from volume-driven models to value-based, patient-centered care, emphasizing shared decision making, evidence-based thresholds, and interdisciplinary collaboration. (PubMed)

2.      Raskin D, Partovi S, Levitin A, Lyden SP, Kirksey L.
A narrative review of imaging misallocation in peripheral artery disease: a value-based medicine perspective.
Cardiovascular Diagnosis and Therapy (Dec 2025).
This article examines how diagnostic imaging in PAD is often misaligned with guideline-recommended pathways and proposes value-based strategies to optimize imaging utilization, equity, and outcomes. (Cardiovascular Diagnosis and Therapy)

Carotid Artery Disease Risk Checklist

Who Should Be Screened or Discuss Stroke Prevention With a Specialist

Carotid artery disease occurs when cholesterol plaque builds up in the arteries supplying blood to the brain. This can increase the risk of stroke or transient ischemic attack (TIA).

Major Risk Factors

Check all that apply:

• ☐ Age 65 or older

• ☐ Male sex

• ☐ High blood pressure (hypertension)

• ☐ High cholesterol

• ☐ Diabetes

• ☐ Current or past smoker

• ☐ Obesity or physical inactivity

• ☐ Chronic kidney disease or dialysis

• ☐ Family history of stroke or early heart disease (before age 60)

Medical History That Raises Concern

• ☐ Prior heart attack or coronary artery disease

• ☐ Known peripheral artery disease (PAD) or leg circulation problems

• ☐ Prior carotid bruit (abnormal neck sound heard by a clinician)

• ☐ History of atrial fibrillation

Stroke or TIA Warning Symptoms

These require urgent medical evaluation:

• ☐ Sudden weakness or numbness of face, arm, or leg (especially on one side)

• ☐ Trouble speaking or understanding speech

• ☐ Sudden vision loss in one eye

• ☐ Sudden dizziness, imbalance, or confusion

• ☐ Symptoms that resolved within minutes to hours (possible TIA)

Lifestyle & Access Factors That Increase Risk

• ☐ Limited access to regular medical care

• ☐ Not taking cholesterol or blood pressure medications

• ☐ Difficulty affording medications

• ☐ Long gaps between medical visits

When to Ask About Carotid Ultrasound

You should discuss carotid artery screening if you:

• Have multiple risk factors, even without symptoms

• Have had TIA or stroke symptoms

• Have known atherosclerosis elsewhere (heart, legs, kidneys)

• Are planning major heart or vascular surgery

Questions Patients Should Ask Their Provider

• “Do I have carotid artery disease?”

• “Would medical therapy alone be appropriate for me?”

• “Do I need further imaging or specialist evaluation?”

• “If intervention is needed, what option is best for my anatomy and health?”

• “What are the stroke rates and experience of the team performing this procedure?”

Key Message for Patients

Not all carotid artery narrowing requires surgery or stenting. The best care is personalized care. Medical therapy alone may be safest for some patients, while others benefit from intervention—especially when performed by an experienced team with excellent outcomes.