TY - JOUR
T1 - Pipeline Endovascular Device vs Stent-Assisted Coiling in Small Unruptured Aneurysms
T2 - A Cost-Effectiveness Analysis
AU - Malhotra, Ajay
AU - Wu, Xiao
AU - Brinjikji, Waleed
AU - Miller, Timothy
AU - Matouk, Charles C.
AU - Sanelli, Pina
AU - Gandhi, Dheeraj
N1 - Publisher Copyright:
© 2019 by the Congress of Neurological Surgeons.
PY - 2019/12/1
Y1 - 2019/12/1
N2 - BACKGROUND: Both stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established. OBJECTIVE: To analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence. METHODS: A decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed. RESULTS: In base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC. CONCLUSION: With increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
AB - BACKGROUND: Both stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established. OBJECTIVE: To analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence. METHODS: A decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed. RESULTS: In base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC. CONCLUSION: With increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
KW - Aneurysms
KW - Coiling
KW - Cost-effectiveness
KW - Flow diversion
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U2 - 10.1093/neuros/nyz130
DO - 10.1093/neuros/nyz130
M3 - Article
C2 - 31329957
AN - SCOPUS:85075968321
SN - 0148-396X
VL - 85
SP - E1010-E1019
JO - Clinical neurosurgery
JF - Clinical neurosurgery
IS - 6
ER -