Comparative effectiveness analysis of Pipeline device versus coiling in unruptured aneurysms smaller than 10 mm

Abstract

OBJECTIVEBoth endovascular coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for treatment of small (< 10 mm) aneurysms. The authors conducted a comparative effectiveness analysis to compare the utility of these treatment methods in terms of health benefits.METHODSA decision-analytical study was performed with Markov modeling methods to simulate patients with small unruptured aneurysms undergoing endovascular coiling, stent-assisted coiling (SAC), or PED placement for treatment. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses were performed to assess model and input parameter uncertainty.RESULTSThe base case calculation for a 50-year-old man reveals PED to have a higher health benefit (17.48 quality-adjusted life years [QALYs]) than coiling (17.44 QALYs) or SAC (17.36 QALYs). PED is the better option in 6020 of the 10,000 iterations in probabilistic sensitivity analysis. When the retreatment rate of PED is lower than 9.53%, and the coiling retreatment is higher than 15.6%, PED is the better strategy. In the 2-way sensitivity analysis varying the retreatment rates from both treatment modalities, when the retreatment rate of PED is approximately 14% lower than the retreatment rate of coiling, PED is the more favorable treatment strategy. Otherwise, coiling is more effective. SAC may be better than PED when the unfavorable outcome risk of SAC is lower than 70% of its reported current value.CONCLUSIONSWith the increasing use of PEDs for treatment of small unruptured aneurysms, the current study indicates that these devices may have higher health benefits due to lower rates of retreatment compared to both simple coiling and stent-assisted techniques. Longer follow-up studies are needed to document the rates of recurrence and retreatment after coiling and PED to assess the cost-effectiveness of these strategies.

Reduced 2-year aneurysm retreatment and costs among patients treated with flow diversion versus non-flow diversion embolization: A Premier Healthcare Database retrospective cohort study

“…Follow-up of the PUFS trial at 3 years showed aneurysm occlusion in 71 of 76 patients with no additional occurrences of the safety endpoints [15]. The efficacy of PEDs has been supported by multiple other groups including a number of study registries [18,21,22,[26][27][28]. The results of our study support a lower retreatment rate after PED embolizations as compared with non-PED treatments.…”

“…Previous studies have examined the cost of PED and coiling treatments [20,23,27,29]. Colby et al [20] investigated the costs of coiling versus flow diversion treatment of anterior circulation aneurysms and noted that total costs were lower among patients treated with flow diversion compared with those treated with stent coiling.…”

“…Moreover, our data set encompasses multiple centers and providers, thus increasing its generalizability. Others have reiterated this finding by showing that PEDs may potentially be less costly than coiling, especially when considering retreatment [27].…”

Anterior Communicating Artery Aneurysms: Anatomical Considerations and Microsurgical Strategies

“…Embolization of large or wide-necked aneurysms can be difficult (34,(55)(56)(57) and requires assistance with stents or balloons, which increases the procedure-related disability and mortality rates (58,59). The development of new interventional materials and improvements in interventional embolization techniques have led to the safe embolization of an increasing number of AcoA aneurysms that were previously difficult to treat by interventional embolization or at great risk of embolization (60)(61)(62)(63)(64)(65)(66). In particular, the application of the latest flow diverters has made treatment simple and safe for many intracranial wide-necked or microvascular aneurysms and recurrent complex aneurysms that were previously difficult to treat by simple embolization (61,62,(64)(65)(66).…”

Advances in endovascular aneurysm management: flow modulation techniques with braided mesh devices

“…39 Other studies have also established the effectiveness and safety of PED treatment in patients with small intracranial aneurysms, with lower rates of retreatment compared with both simple coiling and stent-assisted techniques. [40][41][42] The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device(PREMIER) trial was created to evaluate the safety and efficacy of PED in the treatment of widenecked aneurysms, measuring ≤12 mm, located along the ICA or the vertebral artery. At 1 year, 76.8% of patients had complete occlusion without parent vessel stenosis (≤50%) or retreatment.…”