OBJECTIVES: The Woven Endobridge (WEB) is an emerging endovascular treatment for patients with unruptured intracranial aneurysms. Compared to conventional coiling, WEB has better occlusion rates, and compared to stent-assisted coiling (SAC), WEB has advantage of dismissing the need of long-term anti-platelet medication. The objective was to assess the cost-effectiveness and cost-utility of WEB vs. coiling vs. SAC from the perspective of the German Statutory Health Insurance.

METHODS: A lifetime patient-level simulation model was constructed to simulate patients (mean age: 55, standard deviation:10.2) with an unruptured middle-cerebral artery aneurysm (size: 3-11 mm). Input data were derived from literature (e.g., morbidity, angiographic outcome, retreatment, procedural and rehabilitation costs, utilities and rupture rates) and a retrospective cost data. Incremental cost-effectiveness ratios (ICERs) were calculated and expressed as €/quality-adjusted life years (QALYs) and €/neurologic morbidity avoided (NMA). Deterministic and probabilistic sensitivity analyses (DSA and PSA) were performed.

RESULTS: In the base case, lifetime QALYs were 13.24 for the WEB, 12.92 for SAC and 12.68 for coiling. Lifetime costs were 20,440€ for the WEB, 23,167€ for SAC, and 8,200€ for coiling. The ICER for the WEB was 21,826 €/QALY (27,112 €/NMA) compared to coiling, and -8,501 €/QALY (-4,821 €/NMA) compared to SAC. DSA showed that the discount rate, material costs and retreatment rates had the largest impact on the ICERs, but SAC remained absolutely dominated by both coiling and WEB. At a (hypothetical) willingness-to-pay was of 30,000€/QALY, WEB is the more cost-effective strategy with 53% probability. SAC was the cost-effective method in less than 2%.

CONCLUSIONS: The WEB might be a cost-effective endovascular technique compared to coiling and SAC. Coiling had the lowest cumulative costs, even though the lower occlusion rates resulted in higher retreatment costs. SAC is unlikely cost-effective, and should be restricted as primary option to more complex aneurysms not amenable to either coiling or WEB.