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

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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. The authors conducted a comparative effectiveness analysis to compare the utility of these treatment methods in terms of health benefits.


A 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.


The 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.


With 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.

ABBREVIATIONS IntrePED = International Retrospective Study of Pipeline Embolization Device; mRS = modified Rankin Scale; PED = Pipeline embolization device; QALYs = quality-adjusted life years; SAC = stent-assisted coiling; UIA = unruptured intracranial aneurysm.

Article Information

Correspondence Ajay Malhotra: Yale School of Medicine, New Haven, CT.

INCLUDE WHEN CITING Published online January 11, 2019; DOI: 10.3171/2018.8.JNS181080.

A.M. and X.W. contributed equally to this work and share first authorship.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    Simplified decision tree structure.

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    Bar graph showing distributions of probabilistic sensitivity analysis. Trials lying to the right of zero are those in which PED is the better strategy. EV = endovascular.

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    Upper: One-way sensitivity analysis varying the retreatment rate of coiling. A higher health benefit is more desirable. Lower: One-way sensitivity analysis varying the retreatment rate of PED. A higher health benefit is more desirable.

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    Upper: Two-way sensitivity analysis varying retreatment rates of PED and coiling. The color indicates area where the corresponding strategy is preferred. Lower: Two-way sensitivity analysis varying retreatment rates of PED and SAC. The color indicates area where the corresponding strategy is preferred.



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