Introduction: Flow diversion with the Pipeline Embolization Device (PED) is currently adopted for treatment of a variety of intracranial aneurysms. The elevated risk of thromboembolic complications associated with the device necessitates the need for administration of antiplatelet agents. We sought to assess current dual antiplatelet therapy practices patterns and their associated costs, following PED placement.
Methods: An online questionnaire assessing dual antiplatelet regimens following flow diversion for treatment of intracranial aneurysms was developed and disseminated to 80 neurosurgeons at major academic cerebrovascular centers. Pricing information from two of the largest prescription payers in Massachusetts was used to calculate the monthly cost of these agents.
Results: Twenty-six responses (32.5%) were received. All respondents (100%) affirmed using clopidogrel and aspirin dual antiplatelet therapy as a first-line regimen. Twenty-three (88.5%) routinely use platelet function testing. Eleven respondents (42.3%), each, identified that they administer aspirin/ticagrelor and aspirin/prasugrel to clopidogrel hypo-or non-responders. For uninsured patients, prasugrel was found to have the highest cumulative monthly cost ($471), followed by ticagrelor ($396), clopidogrel ($149), and ticlopidine ($110).
Conclusions: Significant heterogeneity in dual antiplatelet regimens following PED placement and associated costs, exists at major academic neurovascular centers. The most commonly used first line dual antiplatelet regimen consists of aspirin and clopidogrel. Two major alternate protocols involving ticagrelor and prasugrel, are administered to clopidogrel hypo-responders. The optimal dual antiplatelet regimen for patients with cerebrovascular conditions has not been established, given limited prospective data within the neurointerventional literature.
Patient Care: With an increasing emphasis on cost-effective medical therapies and treatments, our study demonstrates that prospective data regarding the optimal duration and type of dual antiplatelet therapy in patients undergoing flow diversion treatment, is needed. Current practice patterns across the US, at academic neurovascular centers, are heterogeneous with little justification for individual regimen.
Learning Objectives: By the conclusion of this session, participants should be able to: (1) recognize that significant heterogeneity exists amongst neurointerventionalists in regards to dual antiplatelet therapy regimen adopted, following Pipeline device placement, especially for patients identified as clopidogrel hypo-responders (2) understand that there exists a significant difference in cost associated with newer drugs such as ticagrelor, in comparison with clopidogrel, and (3) acknowledge that a higher risk of hemorrhagic complications has been observed in retrospective studies in patients who used prasugrel or ticagrelor dual antiplatelet therapies following flow diversion treatment.