Assessment of Dual-Antiplatelet Regimen for Pipeline Embolization Device Placement: A Survey of Major Academic Neurovascular Centers in the United States

INTRODUCTION: 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. MATERIALS AND 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 dualantiplatelet regimen for patients with cerebrovascular conditions has not been established, given limited prospective data within the neurointerventional literature.