Flow diverter with or without adjunctive coils in the treatment of large and giant intracranial aneurysms: a meta-analysis

doi:10.21203/rs.3.rs-4970367/v1

Download PDF

Research Article

Flow diverter with or without adjunctive coils in the treatment of large and giant intracranial aneurysms: a meta-analysis

https://doi.org/10.21203/rs.3.rs-4970367/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Introduction

To evaluate the available evidence on the efficacy and safety of flow diverters (FD) with or without adjunctive coils (C) for the treatment of large and giant aneurysms.

Methods

A systematic review and meta-analysis of relevant studies in PubMed and selected articles up to December 2022 were conducted. The primary objective was to evaluate the rate of favorable occlusion O'Kelly Marotta (OKM) C-D at the last follow-up, while the secondary objective was to assess complication rates. A fixed-effects model was used, and relative risks (RR) and 95% confidence intervals (CI) were calculated.

Results

A total of 146 articles were identified, but only 10 were included in the meta-analysis. This included 541 controlled aneurysms out of a total of 680 large and giant aneurysms from 1,667 patients. We found no statistical differences in favorable OKM C-D outcomes with or without the adjunctive use of coils (RR 1.06 [0.96, 1.17]; p = 0.280). However, FD + C presented fewer complications (RR 0.56 [0.33, 0.95]; I²=0%; p = 0.03). No statistical differences were found for mortality (RR 0.86 [0.34, 2.18]; I²=0%; p = 0.75).

Conclusions

The use of adjunctive coils during treatment of large and giant aneurysms with FD seems to reduce the risk of procedural and delayed complications, while it does not increase the aneurysm occlusion rate.

Cerebral aneurysm

Large

Giant

Flow diverters (FD)

Coils (C)

Meta-analysis

Endovascular treatment (EVT) of large and giant aneurysms is challenging [1]. Coiling of such aneurysms has a high recanalization rate, even if assisted with balloon or stent [2, 3]. The introduction of flow diverters (FD) has changed the treatment of large and giant aneurysms, as well as those with wide necks, dissecting etiology, or fusiform shapes. Nevertheless, studies on FD in large and giant aneurysms are limited. Due to the delayed complete occlusion reported in these studies, some authors recommend adjunctive coiling with the aim to protect the dome, to reduce the intrasaccular flow velocity, and shear wall tension, promoting thrombus formation, early aneurysm occlusion, and reducing the risks of late rupture [2, 4–7]. Although efforts have been made to investigate the best therapeutic option, a consensus has not yet been established, and often it depends on the physician's preference [3]. Moreover, there is a concern about the complication rate related to the adjunctive coiling [3, 8, 9].

We aimed to provide a systematic review and meta-analysis to assess the efficacy and safety of FD with coils (FD + C), in comparison with FD alone for the treatment of large and giant aneurysms.

Protocol and Search Strategy

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as well as the Cochrane manual [10].

We searched Medline electronic database until December 2022. Search terms included MeSH and Emtree terms as well as specific keywords for intracranial aneurysms and endovascular treatment with flow diverters, including: [("Intracranial Aneurysm"[Majr]) AND (large OR giant) AND coils AND (flow divert*)] OR [ ("Intracranial Aneurysm"[Majr]) AND (large OR giant) AND (flow divert*) AND (coils OR not coils)] OR [("Intracranial Aneurysm"[Majr]) AND (large OR giant) AND (flow divert*) AND (coil* OR not coil*)]. Additionally, manual searches were conducted in the reference lists of published articles to ensure the completeness of the bibliography.

We used the PICOS (Patient population, Intervention, Control, Outcome, Study design) framework for the inclusion criteria: (P) adult patients with large and giant intracranial aneurysms; (I) EVT with FD and coils; (C) EVT with FD alone; (O) adequate aneurysm occlusion rate, defined by the O'Kelly Marotta (OKM) grade C or D; secondary: procedural complication rates. Our search focused on interventional studies, either randomized or cohort studies (S).

We excluded non-English or Spanish language studies, unpublished studies, conference abstracts, studies including less than 5 patients, meta-analyses, comments, guidelines, technical notes, editorials, book chapters, and in vitro and animal studies.

Outcomes

The primary outcome was the adequate occlusion rate, defined by the O'Kelly Marotta (OKM) grade C or D. The OKM grading scale is a proposed method of assessing the degree of angiographic filling and contrast stasis in the setting of intracranial aneurysms treated by endovascular flow diversion [11].

Secondary outcomes were rates of procedure-related, hemorrhagic or ischemic complications, and mortality. Procedure-related complications ere defined as deployment complication, FD migration and acute thromboembolism. Hemorrhagic complications were defined as distal wire perforation, early and delayed aneurysm rupture, parenchymal hemorrhage aneurysm, while ischemic complications were defined as transient ischemic attack, minor and mayor cerebral infarction, delayed in-stent stenosis and mass effect.

Study Selection

Two reviewers independently (SME and NF) assessed the titles and abstracts of the articles identified through the search strategy, as well as data extraction. All relevant publications were evaluated by these reviewers, who also determined the final inclusion of studies in the meta-analysis. Concordance between reviewers was assessed using the Covidence program. Disagreements were resolved through consensus in meetings with all authors.

The extracted data included authors, publication year, study design, number of treated patients, large and giant aneurysms treated with FD with or without coils, and the number of uncontrolled aneurysms.

Data Extraction and Quality Assessment

The same reviewers independently extracted data from the included trials. Data extraction was performed using a standardized form to collect this information. The quality of included studies was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies, which evaluates studies based on three main aspects: selection, comparability, and determination of the outcome of interest [12, 13]. The scale sets a maximum score of 9 points, considering studies of high quality if the score is ≥ 7 points. All eligible studies were included regardless of their assessed quality.

Statistical Analysis

This meta-analysis was conducted using the Review Manager program (RevMan 5.4), Jamovi for Microsoft Windows, version 1.6 [Computer Software], and Open Meta Analyst. For each dichotomous outcome, the cumulative incidence (event rate) and the 95% confidence interval (CI) were calculated. Relative risks (RR) for comparison were also calculated using the Mantel-Haenszel method. Due to no heterogeneity among studies, a fixed-effects model was used for all analyses. Publication bias was assessed using a funnel plot based on Egger's regression test. Statistical significance was identified with a p-value < 0.05.

Selected Studies and Quality Assessment

The initial literature search yielded 144 articles, and 2 articles were selected from the manual search. After reviewing abstracts and titles, 107 articles were excluded, and 39 articles were selected for full-text examination. In total, 10 studies were included (8 retrospective cohort studies, 1 prospective study, and 1 case series) (Fig. 1 and Table 1). Among them, 7 studies (70%) had a low risk of bias, while 3 studies (30%) had a high risk of bias. Subsequently, bias risk graphs were generated for each included article, presented as an overall percentage (Supplementary Fig. 1) and individually (Supplementary Fig. 2)

Table 1

Reference data of the articles included. CS (case series). RC (retrospective cohort). PC (Prospective cohort). NOS (Newcastle-Ottawa Scale) Low risk of bias ^*. High risk of bias ^†. FD (Flow diverter)
Study	Year	Study design	Flow diverter specific	Specific of large and giant aneurysms	NOS	N° of patiens	N° of large and giant intracranial aneurysms	N° of uncontrolled aneurysms	N° of aneurysms treated with more than 1 FD	Group	Controlled aneurysms			O´Kelly Marotta Classification
Study	Year	Study design	Flow diverter specific	Specific of large and giant aneurysms	NOS	N° of patiens	N° of large and giant intracranial aneurysms	N° of uncontrolled aneurysms	N° of aneurysms treated with more than 1 FD	Group	Total	Large	Giant	C	D
Chalouhu et al	2013	RC	No	Yes	9^*	160	40	5	13	FD	32	-	-	-	27
Chalouhu et al	2013	RC	No	Yes	9^*	160	40	5	13	FD + C	3	-	-	-	3
Meckek et al	2013	RC	Yes	Yes	6^†	10	10	-	9	FD	3	-	3	1	1
Meckek et al	2013	RC	Yes	Yes	6^†	10	10	-	9	FD + C	7	2	5	3	4
Carneiro et al	2014	CS	Yes	Yes	6^†	8	8	-		FD	2	-	-	-	2
Carneiro et al	2014	CS	Yes	Yes	6^†	8	8	-		FD + C	6	-	-	-	3
Zhou et al	2014	PC	Yes	Yes	7^*	28	28	3	5	FD	8	-	-	1	6
Zhou et al	2014	PC	Yes	Yes	7^*	28	28	3	5	FD + C	17	-	-	5	12
Peschillo et al	2017	RC	Yes	Yes	9^*	44	44	1	8	FD	26	23	3	4	17
Peschillo et al	2017	RC	Yes	Yes	9^*	44	44	1	8	FD + C	18	14	4	1	16
Tejada et al	2019	RC	Yes	Yes	6^†	9	9	-	1	FD	8	8	-	-	8
Tejada et al	2019	RC	Yes	Yes	6^†	9	9	-	1	FD + C	1	1	-	-	1
Choi et al	2020	RC	No	Yes	9^*	112	39	1		FD	33	-	-	9	17
Choi et al	2020	RC	No	Yes	9^*	112	39	1		FD + C	5	-	-	1	2
Lv et al	2020	RC	No	No	7^*	80	41	-	7	FD	16	-	-	-	16
Lv et al	2020	RC	No	No	7^*	80	41	-	7	FD + C	25	-	-	-	25
Kandemirli et al	2022	RC	Yes	Yes	9^*	45	45	-	1	FD	24	-	-	5	15
Kandemirli et al	2022	RC	Yes	Yes	9^*	45	45	-	1	FD + C	21	-	-	-	17
Wang et al	2022	RC	Yes	No	9^*	1171	416	-		FD	98	-	-	-	75
Wang et al	2022	RC	Yes	No	9^*	1171	416	-		FD + C	188	-	-	-	156
Total	-	-	-	-	-	1667	680	10	44		541	48	15	30 (6.6)	423 (93.4)

Study Characteristics and Descriptive Summary

These 10 studies included a total of 1667 patients, of whom 680 had large and giant aneurysms. [1–6, 14–17] Out of these, 541 aneurysms with controls were included in the study. Among the treated aneurysms, 291 (53.8%) were treated with FD + C, and 250 (46.2%) were treated with FD. Only 3 articles (30%) discriminated aneurysm size concerning the therapeutic approach, with 48 classified as large and 15 as giant. Tables 1 provide a summary of the included studies.

Primary Outcome

Among all included patients, the overall adequate occlusion rate (OKM C-D) was 83.9% (453/541; 95% CI 80.8%-87%; I²:0%; p:0.21). When dichotomized by therapeutic modality, the rate was 85.6% (249/291; 95% CI 81.5%-89.6%) in the FD + C group, while 81.6% (204/250; 95% CI 76.8%-86.4%) in the FD group (Supplementary Fig. 3). [1–6, 14–17] Meta-analysis of included studies demonstrated no statistically significant differences between groups (RR 1.06 [0.96, 1.17]; I²:0%; p:0.28) (Fig. 4).

Subgroup analysis of OKM grades did not show statistical differences between groups: in the OKM C subgroup RR 0.62 [0.27, 1.43]; I²:4%; p:0.26, and in the OKM D subgroup RR 1.09 [0.99, 1.20]; I²:0%; p:0.07 (Fig. 4). Egger's regression was performed for each subgroup (p:0.12 for the OKM C subgroup and p:0.96 for the OKM D subgroup), showing no publication bias. The funnel plots show that we need more studies (Supplementary Fig. 4).

Secondary Outcome

The overall complication rate was 10.7% (47/418; 95% CI 7.8%-13.7%; I²:0%; p:0.10).

When dichotomizing by therapeutic modality, the complication rate was 5% (14/169; 95% CI 1.9%-8%; I²:0%: p:0.35) in the FD + C group, and 8.4% (33/249; 95% CI 5.2%-11.7%; I²:0%; p: 0.08) in the FD group.

The rate of device-related complications was 4.3% (5/70; 95% CI 0%-8.7%; I²:0%: p:0.51) in the FD + C group and 19.3% (15/71; 95% CI 10.5%-28.1%; I²:0%; p: 0.59) in the FD group. Hemorrhagic complications were 6.3% (4/49; 95% CI 0%-12.9%; I²:0%: p:0.57) in the FD + C group and 6.2% (6/85; 95% CI 1.1%-11.2%; I²:0%; p: 0.70) in the FD group. Ischemic complications were 5.1% (5/50; 95% CI 0%-10.6%; I²:0%: p:0.06) in the FD + C group and 7.2% (12/93; 95% CI 2.2%-12.2%; I²:0%; p: 0.04) in the FD group (Supplementary Figs. 5 and 6). Meta-analysis of included studies demonstrated lower complications rate for the FD + C group (RR 0.56 [0.33, 0.95]; I²:0%; p:0.03). (Fig. 3)

Subgroup analysis did not show statistically significant differences between groups for FD-related complications (RR 0.46 [0.20, 1.05]; I²:0%; p:0.06), although a trend in favor of FD + C. Also, hemorrhagic complications (RR 1.00 [0.30, 3.34]; I²:0%; p:1.00) and ischemic complications (RR 0.51 [0.22, 1.22]; I²:0%; p:0.45) were not statistically different between groups. Egger's regression for each subgroup (p:0.86 for the FD-related subgroup, p:0.26 for hemorrhagic complications, and p:0.90 for ischemic complications) showed no publication bias. (Supplementary Fig. 7)

Only 5 articles reported mortality rates. The overall mortality rate was 9.8% of treated patients (17/172; 95% CI 5.4%-14.3%; I²:0%; p:0.72): 11.1% (6/54; 95% CI 2.7%-19.5%) in the FD + C group and 9.3% (11/118; 95% CI 4.1%-14.6%) in the FD group (Supplementary Fig. 8). No statistical differences were found for any proposed therapy (RR 0.86 [0.34, 2.18]; I²:0%; p:0.75), (Fig. 4). Egger's regression (p:0.29) showed no publication bias. (Supplementary Fig. 9).

In this meta-analysis, we provide insights into the efficacy and safety of flow diverter treatment with or without coiling of large and giant intracranial aneurysms. The aim was to address the question of which treatment is safer and more effective, given the complexity of such aneurysms and the varying conclusions that should be found in the literature. We found that the adjunctive coiling of the aneurysm did not statistically increase the adequate occlusion rate (OKM C-D). However, the treatment with FD + C was associated with lower complication rates, especially device-related and ischemic complication rates.

Several meta-analyses have attempted to evaluate outcomes and complications with the use of FD, such as the study presented in 2013 by Brinjikji and colleagues [18]. They included 1451 patients with 1654 intracranial aneurysms treated with FD, reporting a complete occlusion rate of 76% (95% CI [70%,81%]) at 6 months, a procedure-related morbidity of 5% (95% CI [4%, 7%]), and a mortality of 4% (95% CI [3%, 6%]). A more recent meta-analysis in 2021 by Jia-Lin Xia and colleagues compared the treatment of unruptured aneurysms with FD versus coil embolization, including 8 studies with 839 patients treated with FD and 2734 with coils. They found a higher rate of complete occlusion at 6 months with the use of FD (OR 0.28 [0.09, 0.85]; I2:82%; p:0.02) [19]. In subgroup analysis, FD treatment was associated with significantly higher complete occlusion rates at 6 months for large or giant aneurysms (OR 0.12 [0.07, 0.21]; I²:0%; p:<0.01), while no differences were observed in non-large/giant aneurysm groups (OR 1.10 [0.46, 2.60]; I²:18%; p:0.83). In 2022, Li and colleagues compared FD treatment with conventional coil treatment, including 18 studies with 1001 patients treated with FD and 1133 with coils [20]. They found that the FD group had larger aneurysms (standardized mean difference [SMD] 0.22 [0.03, 0.41]; p: 0.02). Angiographic results for FD treatment indicated a higher rate of complete occlusion (OR 2.55 [1.70, 3.83]; I²:68%; p:<0.01) and lower rates of recurrence (OR 0.24 [0.12, 0.46]; I²:36%; p:<0.01) and retreatment (OR 0.31 [0.21, 0.47]; I²:30%; p:<0.01). There was a higher risk of complications in the FD group compared to the endovascular coil group (OR 1.4 [1.01, 1.96]; p:0.04).

In our study, we found that 83.9% (453/541; 95% CI 80.8%-87%; I²:0%; p:0.21) had a favorable occlusion rate OKM C-D, consistent with findings presented by Shehata, like the PEDESTRIAN study, and better than those presented by Brinjikji [18, 21, 22]. When dichotomized by therapeutic modality, the FD + C had a favorable occlusion of 85.6% (249/291; 95% CI 81.5%-89.6%), while the FD-only group was 81.6% (204/250; 95% CI 76.8%-86.4%), and the comparison was inconclusive (RR 1.06 [0.96, 1.17]; I²:0 %; p:0.28).This aligns with Sweid and colleagues' findings, although their final recommendation is the combined use for large and giant aneurysms [23]. When analyzing subgroups, we note a statistically significant trend for OKM D in favor of FD without coadjuvant coils (RR 1.09 [0.99, 1.20]; I²:0 %; p:0.07). Als, we highlight that few articles discriminated aneurysm size, limiting statistical power (33.3%).

The PEDESTRIAN study, presented in 2021, reported long-term follow-up on 835 patients with 1000 aneurysms treated with the Pipeline flow diverter [22]. They obtained a low rate of overall complications, including 3.6% (30/835) for stroke (mostly caused by stent thrombosis) and 1.8% (23/835) for hemorrhagic complications. The overall morbidity rate, including subarachnoid hemorrhage, was 2.7% (23/835). The all-cause mortality rate was 4.6% (38/835), with a neurological mortality rate of 3.1% (26/835). Cox logistic regression identified aneurysm size as the only significant predictive factor for neurological death (HR 6.37 [95% CI: 2.41–16.81]; p = 0.01). These findings do not align with the results of this study.

On the contrary, our results coincide with those presented by Sweid, who reported similar hemorrhagic complications between groups (5.5% for coadjuvant coils and 4.8% for FD-only, without statistical significance, p:0.81) as well as ischemic complications (12% for coadjuvant coils and 6.3% for FD-only, without statistical significance, p: 0.21) [23].

Regarding complications, we found that the coadjuvant use of coils resulted in fewer general complications (RR 0.56 [0.33, 0.95]; I²:0%; p:0.03). However, subgroup analysis (related to FD, hemorrhagic, and ischemic complications) was inconclusive, although complications related to FD showed a trend favoring the use of coils (RR 0.46 [0.20, 1.05]; I²:0%; p:0.06).

LIMITATIONS

This study has some limitations. There are no RCT studies, and among the observational studies, most are retrospective. Most of the articles present treatments up to the ophthalmic segment, potentially introducing a bias in the distal and posterior circulation. Some articles used different dimension to define large aneurysms, and it could have an effect in the occlusion rate. Additionally, a specific type of FD was not analyzed, despite known differences. Some articles did not use the OKM classification, requiring adaptation to the mentioned classification, and there was no standardized follow-up time, so the last follow-up was mentioned. The articles that used coils as coadjuvant do not specify the quantity used and do not reference light or dense packing. Despite these limitations, we can draw important conclusions.

In large and giant aneurysms, the use of FD with adjunctive coils seems to not to increase the rate of adequate aneurysm occlusion compared to FD alone. However, our results demonstrated a trend in favor of the adjunctive coiling, in reducing the periprocedural and ischemic risks.

C coils, CI Confidence intervals, CS Case series, FD flow diverter, HR Hazard Ratio, NOS Newcastle-Ottawa Scale, OD Odds Ratio, OKM O´Kelly Marotta, PC Prospective cohort, RC Retrospective cohort, RR Relative risks, SMD Standardized mean difference

Ethical Approval: Not applicable

Funding: Not applicable

Disclosures: The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Acknowledgments: Not applicable

Zhou Y, Yang P, Fang Y, Xu Y, Hong B, Zhao W, Li Q, Zhao, Huang Q, Liu J (2014) A novel flow-diverting device (Tubridge) for the treatment of 28 large or giant intracranial aneurysms: a single-center experience. AJNR Am J Neuroradiol 35:2326–2333. https://doi.org/10.3174/AJNR.A3925
Kandemirli SG, Baltacioglu F, Jesser J, Kizilkilic O, Islak C, Möhlenbruch M, Kocer N (2022) Flow Redirection Endoluminal Device (FRED) with or without Adjunctive Coiling in Treatment of Very Large and Giant Cerebral Aneurysms. Clin Neuroradiol 32:471–480. https://doi.org/10.1007/S00062-021-01061-X
Choi JH, Lee KS, Kim B, soo, Shin YS (2020) Treatment outcomes of large and giant intracranial aneurysms according to various treatment modalities. Acta Neurochir (Wien) 162:2745–2752. https://doi.org/10.1007/S00701-020-04540-1
Tejada JG, Lopez GVV, Koovor JME, Riley K, Martinez M (2019) Mid-term follow-up of staged bilateral internal carotid artery aneurysm treatment with Pipeline embolization. Interv Neuroradiol 25:664–670. https://doi.org/10.1177/1591019919853586
Peschillo S, Caporlingua A, Resta MC, Paul Peluso JP, Burdi N, Sourour N, Diana F, Guidetti G, Clarençon F, Bloemsma GC, Maria F, Di, Donatelli M, Resta M (2017) Endovascular Treatment of Large and Giant Carotid Aneurysms with Flow-Diverter Stents Alone or in Combination with Coils: A Multicenter Experience and Long-Term Follow-up. Oper Neurosurg (Hagerstown) 13:492–502. https://doi.org/10.1093/ONS/OPX032
Wang C, Luo B, Li T, Maimaitili A, Mao G, Song D, Wang Y, Feng W, Wang Y, Shi H, Wan J, Liu J, Guan S, Zhao Y, Zhang H (2022) Comparison of the Pipeline embolisation device alone or combined with coiling for treatment of different sizes of intracranial aneurysms. Stroke Vasc Neurol 7:345–352. https://doi.org/10.1136/SVN-2021-001258
Jing L, Zhong J, Liu J, Yang X, Nikhil P, Meng H, Wang S, Zhang Y (2016) Hemodynamic Effect of Flow Diverter and Coils in Treatment of Large and Giant Intracranial Aneurysms. World Neurosurg 89:199–207. https://doi.org/10.1016/J.WNEU.2016.01.079
Raymond J, Darsaut TE (2011) An approach to recurrent aneurysms following endovascular coiling. J Neurointerv Surg 3:314–318. https://doi.org/10.1136/JNIS.2011.004788
Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, Berez A, Nelson PK (2010) Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol 31:1139–1147. https://doi.org/10.3174/AJNR.A2023
Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, Atkins D, Barbour V, Barrowman N, Berlin JA, Clark J, Clarke M, Cook D, D’Amico R, Deeks JJ, Devereaux PJ, Dickersin K, Egger M, Ernst E, Gøtzsche PC, Grimshaw J, Guyatt G, Higgins J, Ioannidis JPA, Kleijnen J, Lang T, Magrini N, McNamee D, Moja L, Mulrow C, Napoli M, Oxman A, Pham B, Rennie D, Sampson M, Schulz KF, Shekelle PG, Tovey D, Tugwell P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6. https://doi.org/10.1371/JOURNAL.PMED.1000097
O’Kelly CJ, Krings T, Fiorella D, Marotta TR (2010) A novel grading scale for the angiographic assessment of intracranial aneurysms treated using flow diverting stents. Interventional Neuroradiol 16:133–137. https://doi.org/10.1177/159101991001600204
Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605. https://doi.org/10.1007/S10654-010-9491-Z
Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2000) The Newcastle–Ottawa scale (NOS) for assessing the quality of non-randomized studies in metaanalysis. Appl Eng Agric 18:727–734
Carneiro A, Rane N, Küker W, Cellerini M, Corkill R, Byrne JV (2014) Volume changes of extremely large and giant intracranial aneurysms after treatment with flow diverter stents. Neuroradiology 56:51–58. https://doi.org/10.1007/S00234-013-1304-0
Chalouhi N, Tjoumakaris S, Starke RM, Gonzalez LF, Randazzo C, Hasan D, McMahon JF, Singhal S, Moukarzel LA, Dumont AS, Rosenwasser R, Jabbour P (2013) Comparison of Flow Diversion and Coiling in Large Unruptured Intracranial Saccular Aneurysms. Stroke 44:2150–2154. https://doi.org/10.1161/STROKEAHA.113.001785
Meckel S, McAuliffe W, Fiorella D, Taschner CA, Phatouros C, Phillips TJ, Vasak P, Schumacher M, Klisch J (2013) Endovascular treatment of complex aneurysms at the vertebrobasilar junction with flow-diverting stents: initial experience. Neurosurgery 73:386–394. https://doi.org/10.1227/01.NEU.0000431472.71913.07
Lv X, Jiang C, Wu Z, Jiang W, Wang G (2020) Complex cerebral aneurysms: intra-luminal reconstruction using Pipeline flow-diverting stent and the obliteration mechanism. Neuroradiol J 33:91–97. https://doi.org/10.1177/1971400919894879
Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF (2013) Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 44:442–447. https://doi.org/10.1161/STROKEAHA.112.678151
Xia JL, Li GL, Liu HE, Feng-Fei X, Gu XD (2021) Flow-diverting device versus coil embolization for unruptured intracranial aneurysm: A meta-analysis. Medicine 100:e26351. https://doi.org/10.1097/MD.0000000000026351
Li S, Zeng C, Tao W, Huang Z, Yan L, Tian X, Chen F (2022) The Safety and Efficacy of Flow Diversion versus Conventional Endovascular Treatment for Intracranial Aneurysms: A Meta-analysis of Real-world Cohort Studies from the Past 10 Years. AJNR Am J Neuroradiol 43:1004–1011. https://doi.org/10.3174/AJNR.A7539
Shehata MA, Ibrahim MK, Ghozy S, Bilgin C, Jabal MS, Kadirvel R, Kallmes DF (2022) Long-term outcomes of flow diversion for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg. https://doi.org/10.1136/JNIS-2022-019240
Lylyk I, Scrivano E, Lundquist J, Ferrario A, Bleise C, Perez N, Lylyk PN, Viso R, Nella-Castro R, Lylyk P (2021) Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms, Single-Center Registry: Long-Term Angiographic and Clinical Outcomes from 1000 Aneurysms. Neurosurgery 89:443–449. https://doi.org/10.1093/neuros/nyab183
Sweid A, Atallah E, Herial N, Saad H, Mouchtouris N, Barros G, Gooch MR, Tjoumakaris S, Zarzour H, Hasan D, Chalouhi N, Rosenwasser RH, Jabbour P (2018) Pipeline-assisted coiling versus pipeline in flow diversion treatment of intracranial aneurysms. J Clin Neurosci 58:20–24. https://doi.org/10.1016/j.jocn.2018.10.081

No competing interests reported.

Download PDF

Reviewers agreed at journal
03 Sep, 2024
Reviewers invited by journal
03 Sep, 2024
Editor assigned by journal
02 Sep, 2024
Submission checks completed at journal
28 Aug, 2024
First submitted to journal
24 Aug, 2024

You are reading this latest preprint version

Flow diverter with or without adjunctive coils in the treatment of large and giant intracranial aneurysms: a meta-analysis

Status:

Version 1

Abstract

Introduction

Methods

Results

Conclusions

Figures

INTRODUCTION

MATERIALS AND METHODS

Protocol and Search Strategy

Outcomes

Study Selection

Data Extraction and Quality Assessment

Statistical Analysis

RESULTS

Selected Studies and Quality Assessment

Study Characteristics and Descriptive Summary

Primary Outcome

Secondary Outcome

DISCUSSION

LIMITATIONS

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1