Comparing Retreatments and Expenditures in Flow Diversion Versus Coiling for Unruptured Intracranial Aneurysm Treatment: A Retrospective Cohort Study Using a Real-World National Database

Abstract

BACKGROUND Flow diverters (FDs) have marked the beginning of innovations in the endovascular treatment of large unruptured intracranial aneurysms, but no multi-institutional studies have been conducted on these devices from both the clinical and economic perspectives. OBJECTIVE To compare retreatment rates and healthcare expenditures between FDs and conventional coiling-based treatments in all eligible cases in Japan. METHODS We identified patients who had undergone endovascular treatments during the study period (October 2015-March 2018) from a national-level claims database. The outcome measures were retreatment rates and 1-yr total healthcare expenditures, which were compared among patients who had undergone FD, coiling, and stent-assisted coiling (SAC) treatments. The coiling and SAC groups were further categorized according to the number of coils used. Retreatment rates were analyzed using Cox proportional hazards models, and total expenditures were analyzed using multilevel mixed-effects generalized linear models. RESULTS The study sample comprised 512 FD patients, 1499 coiling patients, and 711 SAC patients. The coiling groups with ≥10 coils and ≥9 coils had significantly higher retreatment rates than the FD group with hazard ratios of 2.75 (1.30-5.82) and 2.52 (1.24-5.09), respectively. In addition, the coiling group with ≥10 coils and SAC group with ≥10 coils had significantly higher 1-year expenditures than the FD group with cost ratios (95% CI) of 1.30 (1.13-1.49) and 1.31 (1.15-1.50), respectively. CONCLUSION In this national-level study, FDs demonstrated significantly lower retreatment rates and total expenditures than conventional coiling with ≥ 9 coils.

Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms

“…23,26) Although previous studies included small aneurysms, aneurysms in locations other than the ICA, or FD approaches other than the PED, the reported cost of FD treatment was lower than that for coil embolization, 25,34,35,37,[38][39][40][41] especially when 9 or more coils were required during the coil embolization procedure. 34) However, almost all previous studies reported the costs for the entire hospital stay, including device costs. Coby et al 40) reported a lower cost of implants and of the total procedure in the PED group.…”

“…Direct comparisons between coil embolization and FD devices have been reported 23,24,26,[31][32][33][34][35] ; however, this is the only study to directly compare coil embolization and PED treatment in large unruptured paraclinoid aneurysms.…”

Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion: A case report and review of the literature

“…Retreatment rates among both FDAC and SAC have been shown to be significantly lower than coil embolization alone, with equivocal safety profiles in complex lesions. [ 5 41 42 ] Likely owing to the added benefit of diversion of laminar flow secondary to increased coverage, FDAC has also been reported to have significantly lower retreatment rates as compared to SAC. [ 5 41 42 ] Furthermore, FDAC has shown to be more cost-effective as compared to SAC, likely owing to the decreased number of coils required in dual-modality treatment.…”

“…[ 5 41 42 ] Likely owing to the added benefit of diversion of laminar flow secondary to increased coverage, FDAC has also been reported to have significantly lower retreatment rates as compared to SAC. [ 5 41 42 ] Furthermore, FDAC has shown to be more cost-effective as compared to SAC, likely owing to the decreased number of coils required in dual-modality treatment. This observation is intuitive, as in SAC, the stent exists to support and prevent prolapse of a large coil mass, which is the primary treatment modality, whereas in FDAC, the coils provide apposition and an immediate safety net for the delayed primary modality of FD.…”

Flow-diverting device versus coil embolization for unruptured intracranial aneurysm

“…[ 1 ] There have additionally been multiple studies published comparing CE and FDD approaches for the treatment of IAs since the publication of this previous meta-analysis. [ 17 – 19 ]…”