1. XIX SYMPOSIUM NEURORADIOLOGICUM W. Casagrande MD, S. Garbugino MD
Bologna October 4-9, 2010
COST-EFECTIVENESS IN EVT OF WIDE NECKED ANEURYSMS: Assisted coilng vs. Flow Diverter Silk Stent
L. Lemme-Plaghos, MD
W. Casagrande MD, S. Garbugino MD
ARGENTINA

2. Large & Wide Neck Brain Aneurysms
Wide necked brain aneurysms may be currently treated either by stent assisted coiling or with the recently introduced flow diverters stents.

3. Large & Wide Neck Brain Aneurysms
Pre embolization
Stent deployed
Endotelization
Flow diverter Silk Stent

4. Large & Wide Neck Brain Aneurysms
4 month FU DSA
Flow diverter Silk Stent

5. Large & Wide Neck Brain Aneurysms
OBJECTIVE:
We report our initial experience in cost-efectiveness comparing two series of cases treated with each technique in between june 2008 and december 2009.

6. Large & Wide Neck Brain Aneurysms
POPULATION & METHODS:
All 23 consecutive large (10-20 mm) and wide neck (more than 4 mm) aneurysms were registered in a prospective database. We assessed clinical history, aneurysm dimensions, indications for stenting, procedure technical details, degree of aneurysm initial occlusion, angiographic and clinical findings at follow-up, and complications.

7. Large & Wide Neck Brain Aneurysms
POPULATION & METHODS:
Group A: 13 patients treated with self expanding Neuroform3 (Boston Scientific) an open cell stent which, deployed over the aneurysm neck, precluded from platinum coils migration after their detachment in the aneurysm sac.
Group B: 10 patients treated using solely the Silk Stent (Balt Extrusion) a nitinol, flexible, specifically designed with microcell, self-expanding flow diverter device.

8. Large & Wide Neck Brain Aneurysms
POPULATION & METHODS:
Patients continued three month antiplatelet medication and follow-up angiogram was performed at the fourth and twelfth. For the purpose of this report´s analysis it was considered as final results those observed after a one year complete follow-up which included 3 and 12 month DSA.

9. Large & Wide Neck Brain Aneurysms
COST ANALYSIS:
For the purpose of cost analysis a conventional stent assisted coiling procedure was considered as one “Embolization Unit” which included one Neuroform3 stent device as well as 12.6 coils bare platinum coils (media of number of coils used per procedure observed in the cases treated in this series).

10. One year follow up results:
Group A: required of 18 procedures since a second embolization was performed in five cases due to coil compaction observed in their 3 month follow up angiogram.
Group B: required only one Silk deployment procedure per case.

11. One year follow up results:
Stent and coils cases group showed complete occlusion (grade A ISAT) of the aneurysm in 7 (53%) patients and a minor neck remnant (grade B ISAT) in 2 (15%). Total 68%.

12. One year follow up results:
TOTAL OCCLUSION
A: pre-treatment
B: cross guidewire
C: “silk” deployed
D: post treatment
E: 3 month FU
Flow diverter group showed 7 (70%) complete occlusions and 2 (20%) subtotal occlusion. Total 90%.

13. One year follow up results:
Group A: 2 (15%) cases presented with intra operative stent occlusion with no permanent deficit Group B: 3 (30%) flow diverters presented with intraprocedural occlusion with recanalization after ReoPro administration and no permanent morbidity.

14. Cost Analysis Results:
Group A (stent and coils treatment) due to second embolization procedures demanded 1.29 embolization units while Group B (Silk cases) although using a more expensive device than the conventional stent but not using coils and not needing second procedures kept a 1.35 embolization units cost….

15. Conclusions:
The Silk flow diverter stent allows appropriate embolization of wide necked large cerebral aneurysms with better result than stent assisted coiling therapy while having a slightly higher procedure cost. Anyhow more experience and longer term follow-up are required to establish final occlusion rates and evolution of stented aneurysms with this devices.

16. Conclusions:
Anyhow… Should indication for Silk flow diverter stent kept restricted to large and wide neck aneurysms solely...? Would these cost efectiveness results change dramatically if coils would be required in Silk cases?

17. Large & Wide Neck Brain Aneurysms
And finally…
However we must consider that health systems' budgets do not increase at the same rate as medical care costs do and that includes our procedures of interventional neuroradiology.