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J Neurosurg. 2019 Jan 11:1-9. doi: 10.3171/2018.8.JNS181080. [Epub ahead of print]

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

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1Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut.
2Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
3Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut.
4Department of Radiology, Northwell Health, Manhasset, New York; and.
5Division of Interventional Neuroradiology, Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland.


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.


IntrePED = International Retrospective Study of Pipeline Embolization Device; PED = Pipeline embolization device; Pipeline embolization device; QALYs = quality-adjusted life years; SAC = stent-assisted coiling; UIA = unruptured intracranial aneurysm; cost-effectiveness analysis; endovascular coiling; intracranial aneurysm; mRS = modified Rankin Scale; vascular disorders


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