Gaughen, John R.

Introduction: Intracranial aneurysm (IA) and abdominal aortic aneurysm (AAA) rupture carry high mortality (40% and 75% respectively) and substantial morbidity in survivors. Recent research suggests that IA and AAA share genetic risk in addition to environmental factors. Retrospective data from our institution identified a population harboring both IA and AAA and showed a high rupture rate for IA (44.2%). We previously demonstrated that screening for AAA in patients with IA is cost-effective based on estimated and published data. We hypothesize that screening for IA in patients with AAA is also cost-effective. Method: We developed a decision-making model using TreeAge Pro 2013 software assuming a hypothetical population with known AAA and truncated screening versus no screening for IA using magnetic resonance angiography. Based on IA size and location, patients were either treated endovascularly or placed on surveillance. Proportions, risks, utilities, and costs for each decision arm were derived from literature. Results: At a given rupture rate, incremental effectiveness varied linearly with coprevalence of AAA and IA. For an assumed rupture rate of 5%/year, screening was effective for coprevalence >6.8% (top graph) and was cost-effective for coprevalence >7.7%. The incremental cost-effectiveness ratio (ICER) favored screening (ICER=$54,193/QALY) at a 7.8% coprevalence and dropped to $27,841.50/QALY at 8.8% coprevalence. Our model was sensitive to IA rupture rate as well as coprevalence (bottom graph). Conclusion: Our model suggests the cost-effectiveness of screening for IA in patients with AAA, below the accepted societal threshold of an ICER $60,000/QALY at a coprevalence ≥7.8% and IA rupture rate ≥5%. These are plausible assumptions for this genetically high-risk population. Further prospective study is warranted to establish coprevalence of AAA and IA, rupture rates, and determine the benefit of dedicated screening.

Background and Purpose: Based on promising results of the Solitaire FR With the Intention for Thrombectomy (SWIFT) trial, Solitaire FR stent retriever device recently received the Food and Drug Administration (FDA) approval for recanalization of cerebral vessels in patients with acute ischemic stroke. Real world experience with this device since its FDA approval in the United States has not been previously described. Methods: We conducted retrospective analysis of consecutive acute ischemic strokes cases from March 2012 to July 2012 in 10 centers within the United States, where Solitaire FR was used as a single device or in conjunction with other intra-arterial endovascular approaches. Results: A total of 107 patients were identified (mean age, 64 years; male gender, 51%; mean admission NIHSS score 17). Mean time from symptom onset to angiogram (groin puncture) was 4 hrs 47 min. Intravenous thrombolysis with tissue plasminogen activator (tPA) was administered in 37% of cases. Other endovascular techniques utilized in conjunction with Solitaire FR included intra-arterial thrombolysis with tPA (12% of patients), aspiration thrombectomy with Penumbra system (29%) and stenting (17%). Complete recanalization (TIMI 2-3) was achieved in 88% of patients. The rate of sICH within the first 24 hours was 15%. In-hospital mortality was 24%. 30-day clinical follow up data was available on 82 (77%) patients. Of those, 28 patients (34%) had favorable functional outcome (defined as modified Ranking Scale,mRS≤2) and 22 patients (27%) had excellent functional outcome (mRS≤1) at 30 days. Three or more passes with the Solitaire device was associated with a higher incidence of mortality compared with patients requiring 1 or 2 passes only (43% and 18% respectively, p = 0.011). No statistically significant correlation between clot location or length and outcome was evident. Use of other devices with the Solitaire FR was correlated with worsened outcome (p=0.037). Conclusions: This is the first study describing real-world experience with Solitaire FR device outside the SWIFT trial in the United States. Out study shows that variety of other endovascular approaches are used in conjunction with Solitaire FR.