title: Assessment of Dual-Antiplatelet Regimen for Pipeline Embolization Device Placement: A Survey of Major Academic Neurovascular Centers in the United States.
abstract: BACKGROUND
  Flow diversion with the Pipeline Embolization Device (PED) currently is 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 after PED placement.
  
  
  METHODS
  An online questionnaire that assessed dual-antiplatelet regimens after flow diversion for treatment of intracranial aneurysms was developed and disseminated to 80 neurosurgeons at major academic cerebrovascular centers. Pricing information from 2 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 nonresponders. 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 after 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 hyporesponders. The optimal dual-antiplatelet regimen for patients with cerebrovascular conditions has not been established, given limited prospective data within the neurointerventional literature.
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Raghav
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Justin M
authors.initials: JM
authors.lastname: Moore
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Christoph J
authors.initials: CJ
authors.lastname: Griessenauer
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Nimer
authors.initials: N
authors.lastname: Adeeb
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Apar S
authors.initials: AS
authors.lastname: Patel
authors.affiliation: Walgreen Company, Illinois, Chicago, USA.
authors.forename: Roy
authors.initials: R
authors.lastname: Youn
authors.affiliation: Walgreen Company, Illinois, Chicago, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Poliskey
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Ajith J
authors.initials: AJ
authors.lastname: Thomas
authors.affiliation: Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: cogilvy@bidmc.harvard.edu.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ogilvy
mesh_terms: D000047:Academies and Institutes; D002561:Cerebrovascular Disorders / Q000191:economics / Q000628:therapy*; D003365:Costs and Cost Analysis; D004621:Embolization, Therapeutic / Q000191:economics / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D000069471:Neurosurgeons / Q000523:psychology; D017063:Outcome Assessment, Health Care; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000627:therapeutic use*; D011795:Surveys and Questionnaires; D014481:United States
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: Cerebral aneurysm; Dual-antiplatelet therapy; Embolization; Flow diversion; Pricing