Safety and Efficacy of Flow Diversion for Intracranial Aneurysms in Small Parent Vessels: A Retrospective Cohort Study
DOI:
https://doi.org/10.6000/1929-6029.2025.14.42Keywords:
Intracranial aneurysms, flow diversion, small parent vessels, safety, efficacy, complicationsAbstract
Background: Intracranial aneurysms arising from small parent vessels (<2 mm) are challenging due to their fragile anatomy and distal locations. Flow diversion (FD) offers a promising treatment, but its safety and efficacy in small vessels remain underexplored.
Objective: To evaluate angiographic occlusion rates and procedure-related morbidity associated with flow diversion for intracranial aneurysms arising from parent vessels <2 mm in diameter.
Methods: A retrospective cohort study was conducted at Bicêtre Hospital, Paris, France, from January 2018 to December 2023, analyzing 50 patients undergoing 56 procedures for 55 aneurysms. FD devices (e.g., Silk Vista Baby, Pipeline Flex) were used. Follow-up at 6, 18, and 42 months assessed occlusion via digital subtraction angiography (DSA) using Raymond-Roy and O’Kelly-Marotta scales.
Results: Complete occlusion was achieved in 70.9% (39/55) of aneurysms at a mean follow-up of 17.86 months. At 6, 18, and 42 months, occlusion rates were 56.4%, 55.6%, and 76.5%, respectively. Intraprocedural complications occurred in 28.6% (16/56) of procedures, with 19.6% (11/56) due to in-stent thrombosis. Symptomatic major complications were observed in 17.9% (10/56), including ischemic events and hemorrhage, and permanent FD-related morbidity was 8.0% (4/50).
Conclusion: FD is effective for small vessel aneurysms, with high occlusion rates, but significant complications highlight the need for careful patient selection and refined techniques. Larger studies are needed to optimize outcomes.
References
Burkhardt J-K, McGuire LS, Griessenauer CJ. Flared non-flow diverting ends of the FRED flow diverter for cerebral aneurysms facilitate device anchoring at the arterial bifurcation. The Neuroradiology Journal 2021; 34(5): 521-524. DOI: https://doi.org/10.1177/19714009211013508
Ocal O, Peker A, Balci S, Arat A. Placement of a stent within a flow diverter improves aneurysm occlusion rates. American Journal of Neuroradiology 2019; 40(11): 1932-1938. DOI: https://doi.org/10.3174/ajnr.A6237
Möhlenbruch MA, Kizilkilic O, Killer-Oberpfalzer M, Baltacioglu F, Islak C, Bendszus M, Cekirge S, Saatci I, Kocer N. Multicenter experience with FRED Jr flow re-direction endoluminal device for intracranial aneurysms in small arteries. American Journal of Neuroradiology 2017; 38(10): 1959-1965. DOI: https://doi.org/10.3174/ajnr.A5332
Martínez-Galdámez M, Biondi A, Kalousek V, Pereira VM, Ianucci G, Gentric J-C, Mosimann PJ, Brisbois D, Schob S, Quäschling U. Periprocedural safety and technical outcomes of the new Silk Vista Baby flow diverter for the treatment of intracranial aneurysms: Results from a multicenter experience. Journal of Neurointerventional Surgery 2019; 11(7): 723-727. DOI: https://doi.org/10.1136/neurintsurg-2019-014770
Bhogal P, Makalanda HLD, Wong K, Keston P, Downer J, Du Plessis JC, Nania A, Simonato D, Fuschi M, Chong W. The silk vista baby-the UK experience. Interventional Neuroradiology 2022; 28(2): 201-212. DOI: https://doi.org/10.1177/15910199211024061
Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC. The barrow ruptured aneurysm trial: 3-year results. Journal of Neurosurgery 2013; 119(1): 146-157. DOI: https://doi.org/10.3171/2013.3.JNS12683
Zarrintan A, Ghozy S, Maroufi SF, Reda A, Brinjikji W, Kadirvel R, Kallmes DF. Efficacy and safety of flow diverters in retreatment of recurrent intracranial aneurysms—A systematic review and meta-analysis. Interventional Neuroradiology 2024; 15910199241282713. DOI: https://doi.org/10.1177/15910199241282713
Kühn AL, Hou SY, Puri AS, Silva CF, Gounis MJ, Wakhloo AK. Stent-assisted coil embolization of aneurysms with small parent vessels: Safety and efficacy analysis. Journal of NeuroInterventional Surgery 2016; 8(6): 581-585. DOI: https://doi.org/10.1136/neurintsurg-2015-011774
Shi S, Long S, Hui F, Tian Q, Wei Z, Ma J, Yang J, Wang Y, Han X, Li T. Safety and efficacy of LVIS Jr stent-assisted coiling of intracranial aneurysms in small-diameter parent arteries: A single-center experience. Clinical Neuroradiology 2024; 34(3): 587-595. DOI: https://doi.org/10.1007/s00062-024-01397-0
Ozaki T, Fujinaka T, Kidani T, Nishimoto K, Yamazaki H, Sawada H, Taki K, Kanemura Y, Nakajima S. Coil embolization of unruptured cerebral aneurysms using stents in small arteries less than 2 mm in diameter. Neurosurgery 2022; 90(5): 538-546. DOI: https://doi.org/10.1227/neu.0000000000001876
Caroff J, Neki H, Mihalea C, D’Argento F, Khalek HA, Ikka L, Moret J, Spelle L. Flow-diverter stents for the treatment of saccular middle cerebral artery bifurcation aneurysms. American Journal of Neuroradiology 2016; 37(2): 279-284. DOI: https://doi.org/10.3174/ajnr.A4540
Li T, Shi S, Chen Q, Jiang C, Feng W, Tian Q, Long S, Wei Z, Yang J, Wang Y. Use of the Neuroform Atlas stent or LVIS Jr stent for treatment of unruptured intracranial aneurysms in parent arteries of< 2 mm in diameter: A multicenter experience. American Journal of Neuroradiology 2024; 45(7): 899-905. DOI: https://doi.org/10.3174/ajnr.A8238
Hanel RA, Cortez GM, Coon AL, et al. Surpass intracranial aneurysm embolization system pivotal trial to treat large or giant wide-neck aneurysms-SCENT: 3-year outcomes. Journal of Neurointerventional Surgery 2023; 15(11): 1084-1089. DOI: https://doi.org/10.1136/jnis-2022-019512
Kallmes DF, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. American Journal of Neuroradiology 2015; 36(1): 108-115. DOI: https://doi.org/10.3174/ajnr.A4111
Pierot L, Spelle L, Berge J, Januel A-C, Herbreteau D, Aggour M, Piotin M, Biondi A, Barreau X, Mounayer C. SAFE study (Safety and efficacy Analysis of FRED Embolic device in aneurysm treatment): 1-year clinical and anatomical results. Journal of NeuroInterventional Surgery 2019; 11(2): 184-189. DOI: https://doi.org/10.1136/neurintsurg-2018-014261
Kallmes DF, Brinjikji W, Boccardi E, Ciceri E, Diaz O, Tawk R, Woo H, Jabbour P, Albuquerque F, Chapot R. Aneurysm study of pipeline in an observational registry (ASPIRe). Interventional Neurology 2016; 5(1-2): 89-99. DOI: https://doi.org/10.1159/000446503
Gory B, Berge J, Bonafé A, Pierot L, Spelle L, Piotin M, Biondi A, Cognard C, Mounayer C, Sourour N. Flow diverters for intracranial aneurysms: The DIVERSION national prospective cohort study. Stroke 2019; 50(12): 3471-3480. DOI: https://doi.org/10.1161/STROKEAHA.119.024722
Becske T, Potts MB, Shapiro M, Kallmes DF, Brinjikji W, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ. Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. Journal of Neurosurgery 2016; 127(1): 81-88. DOI: https://doi.org/10.3171/2015.6.JNS15311
Hanel RA, Cortez GM, Lopes DK, Nelson PK, Siddiqui AH, Jabbour P, Pereira VM, István IS, Zaidat OO, Bettegowda C. Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification. Journal of Neurointerventional Surgery 2023; 15(3): 248-254. DOI: https://doi.org/10.1136/neurintsurg-2021-018501
Bender MT, Zarrin DA, Campos JK, Lin L-M, Huang J, Caplan JM, Tamargo RJ, Colby GP, Coon AL. Tiny pipes: 67 cases of flow diversion for aneurysms in distal vessels measuring less than 2.0 mm. World Neurosurgery 2019; 127: e193-e201. DOI: https://doi.org/10.1016/j.wneu.2019.02.204
Rodríguez-Fernández C, Ruiz-Garcia P, Garcia-Sanchez MJ, Manrique-Zegarra M, Toledano-Illán C, Escartin J, Vences MA, Rubio LA, Luttich A, Pumar JM. Technical success, procedural safety, and efficacy of the Silk Vista Baby in the treatment of cerebral aneurysms over a mid-to-long-term follow-up. Frontiers in Neurology 2024; 15: 1369443. DOI: https://doi.org/10.3389/fneur.2024.1369443
Schob S, Richter C, Scherlach C, Lindner D, Planitzer U, Hamerla G, Ziganshyna S, Werdehausen R, Struck MF, Schob B. Delayed stroke after aneurysm treatment with flow diverters in small cerebral vessels: A potentially critical complication caused by subacute vasospasm. Journal of Clinical Medicine 2019; 8(10): 1649. DOI: https://doi.org/10.3390/jcm8101649
Cagnazzo F, Limbucci N, Nappini S, Renieri L, Rosi A, Laiso A, di Carlo DT, Perrini P, Mangiafico S. Flow-diversion treatment of unruptured saccular anterior communicating artery aneurysms: A systematic review and meta-analysis. American Journal of Neuroradiology 2019; 40(3): 497-502. DOI: https://doi.org/10.3174/ajnr.A5967
Pagiola I, Mihalea C, Caroff J, Ikka L, Chalumeau V, Yasuda T, de la Torre JM, Iacobucci M, Ozanne A, Gallas S. Flow diversion treatment of aneurysms of the complex region of the anterior communicating artery: Which stent placement strategy should ‘I’use? A single center experience. Journal of NeuroInterventional Surgery 2019; 11(11): 1118-1122. DOI: https://doi.org/10.1136/neurintsurg-2019-014858
Cagnazzo F, Cappucci M, Dargazanli C, Lefevre P-H, Gascou G, Riquelme C, Bonafe A, Costalat V. Treatment of distal anterior cerebral artery aneurysms with flow-diverter stents: A single-center experience. American Journal of Neuroradiology 2018; 39(6): 1100-1106. DOI: https://doi.org/10.3174/ajnr.A5615
Ravindran K, Enriquez-Marulanda A, Kan PT, Renieri L, Limbucci N, Mangiafico S, Salem MM, Alturki AY, Moore JM, Ogilvy CS. Use of flow diversion for the treatment of distal circulation aneurysms: A multicohort study. World Neurosurgery 2018; 118: e825-e833. DOI: https://doi.org/10.1016/j.wneu.2018.07.062
Salem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Massari F, Moore JM, Tjoumakaris SI, Jabbour P. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: Multicenter cohort. Journal of Neurointerventional Surgery 2022; 14(11): 1084-1089. DOI: https://doi.org/10.1136/neurintsurg-2021-018224
Popica DA, Cortese J, Oliver AA, Plaforet V, Diaz IM, Rodriguez-Erazú F, Ikka L, Mihalea C, Chalumeau V, Kallmes DF. Flow diverter braid deformation following treatment of cerebral aneurysms: Incidence, clinical relevance, and potential risk factors. Journal of Neurointerventional Surgery 2024. DOI: https://doi.org/10.1136/jnis-2024-022236
Cooper JB, Greisman JD, Dakay K, Kaur G, Al-Mufti F, Gandhi CD, Santarelli JG. Incidence of neo-intimal hyperplasia in anterior circulation aneurysms following pipeline flow diversion. Journal of Stroke and Cerebrovascular Diseases 2021; 30(7): 105794. DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105794
Ravindran K, Salem MM, Enriquez-Marulanda A, Alturki AY, Moore JM, Thomas AJ, Ogilvy CS. Quantitative assessment of in-stent stenosis after pipeline embolization device treatment of intracranial aneurysms: A single-institution series and systematic review. World Neurosurgery 2018; 120: e1031-e1040. DOI: https://doi.org/10.1016/j.wneu.2018.08.225
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