Cost-Effectiveness Analytic Comparison of Neuroimaging Follow-Up Strategies After Pipeline Embolization Device Treatment of Unruptured Intracranial Aneurysms.

ABSTRACT Background Flow diversion via Pipeline Embolization Device (PED) is one of the established modalities for treatment of unruptured intracranial aneurysms that require a robust follow-up regimen. However, to date, there is no consensus regarding the optimal imaging modality and timing intervals for such a strategy. We sought to study the cost-effectiveness of different neuroimaging follow-up strategies after flow diversion with PED. Methods A decision-analytical study using Markov modeling was performed to compare five commonly used multistep follow-up strategies utilizing different combinations of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): 1) DSA 6, MRA 12, 24 months. 2) DSA 6, 12, 24 months. 3) MRA 6, 12, 24 months. 4) DSA 6, 12, MRA 24 months. 5) DSA 12, MRA 24 months. Input parameters were mainly collected from the current meta-analysis; and 1-way, 2-way, and probabilistic sensitivity analyses were conducted to assess the robustness of our model. Results Strategy 5 incorporating DSA at 12 months and MRA at 24 months was the most cost-effective strategy in >99% of the 10,000 iterations in probabilistic sensitivity analysis (PSA) at a willingness-to-pay threshold of $100,000/QALY. The result remains robust in one way and two-way sensitivity analysis. Conclusion Given the current literature, delayed imaging follow-up at one year with DSA and two years with MRA after PED treatment of unruptured intracranial aneurysms is more cost-effective than early follow-up at 6 months.