Introduction: Both endovascular coiling and the Pipeline Embolization Device (PED) have been shown to be safe and clinically effective for treatment of small (<10 mm) aneurysms. We conducted a comparative effectiveness analysis to compare their utility in terms of health benefits.
Methods: A decision-analytical study was performed with Markov modeling methods to simulate patients with small unruptured aneurysms undergoing endovascular coiling versus PED for treatment. Input probabilities were derived from prior literature, and one-way, two-way and probabilistic sensitivity analyses were performed to assess model and input parameter uncertainty.
Results: The base case calculation for a patient older than 50-years shows PED to have a higher health benefit (17.48 quality-adjusted life years (QALY)) than coiling (17.44 QALY). PED is the better option in 6,141 of the 10,000 iterations in probabilistic sensitivity
analysis. When the re-treatment rate of PED is lower than 9.53%, and the coiling re-treatment is higher than 15.6%, PED is the better strategy. In the two-way sensitivity analysis varying the re-treatment rates from both treatment modalities, when the
re-treatment of PED is approximately 14% lower than the re-treatment of coiling, PED is the more favorable treatment strategy. Otherwise, coiling is more effective.
Conclusions: With the increasing use of PED for treatment of small unruptured aneurysms, our study indicates that PED may have higher health benefits, due to lower rates of re-treatment. Longer follow-up studies are needed to document the rates of recurrence and
re-treatment after coiling and PED to assess cost effectiveness of these strategies.
Patient Care: This study provides additional information (from a "health benefits" perspective) on deciding between endovascular coiling treatment with a PED for small intracranial aneurysms.
Learning Objectives: To understand the "health benefits" of a strategy of endovascular coiling versus PED treatment for small, unruptured aneurysms.
References: 1. Crobeddu E, Lanzino G, Kallmes DF, et al. Marked decrease in coil and stent utilization following introduction of flow diversion technology. J Neurointerv Surg 2013;5(4):351-3.
2. Griessenauer CJ, Ogilvy CS, Foreman PM, et al. Pipeline Embolization Device for small intracranial aneurysms: evaluation of safety and efficacy in a multicenter cohort. Neurosurgery 2017;80(4):579-87.
3. Malhotra A, Wu X, Forman HP, et al. Growth and rupture risk of small unruptured intracranial aneurysms: a systematic review. Ann Intern Med 2017;167(1):26-33.