# Comparative safety, efficacy, and predictors of complete occlusion of flow diverter devices in the treatment of unruptured distal anterior cerebral artery aneurysms

## TL;DR

This study compares the safety and effectiveness of three flow diverter devices for treating unruptured brain aneurysms and finds that device type does not affect outcomes, while other factors like patient sex and treatment approach matter.

## Contribution

The study provides the first comparative analysis of three flow diverter devices for distal anterior cerebral artery aneurysms and identifies clinical predictors of complete occlusion.

## Key findings

- Pipeline, Silk Vista Baby, and FRED Jr. FDs showed similar safety and efficacy for unruptured DACA aneurysms.
- Complete occlusion was predicted by female sex, asymptomatic presentation, smaller aneurysm neck, radial access, and aspirin plus ticagrelor therapy.
- Device type was not a significant predictor of complete occlusion.

## Abstract

Flow diverters (FDs) are increasingly used for cerebral aneurysms, including distal anterior cerebral artery (DACA) aneurysms, but comparative data between devices in this challenging location are limited.

To compare the safety and efficacy of Pipeline, Silk Vista Baby (SVB), and FRED Jr. FDs for unruptured DACA aneurysms and identify predictors of complete occlusion.

We retrospectively analyzed 166 patients treated with FDs at 39 centers in 14 countries (2018–2022) from the CRETA registry. Outcomes included aneurysm occlusion (O’Kelly–Marotta [OKM] scale), complications, retreatment, modified Rankin Scale (mRS) scores, and independent predictors of complete occlusion using multivariable Cox regression.

Aneurysms were predominantly saccular and located on the pericallosal artery. Complete occlusion (OKM D) was achieved in 73%, and neck remnants (OKM C) in 12%, with no differences across devices. Ischemic complications occurred in 11% (mostly asymptomatic), hemorrhagic complications in 5%, and in-stent stenosis in 17%. Retreatment was performed in 1.3%. At last follow-up, 98% had mRS ≤ 2. Independent predictors of complete occlusion were female sex (HR 1.85), asymptomatic presentation (HR 1.79), smaller aneurysm neck (HR 0.83/mm), radial access (HR 2.20), and aspirin plus ticagrelor therapy (HR 1.84); device type was not predictive.

Pipeline, SVB, and FRED Jr. FDs show similar safety and efficacy for unruptured DACA aneurysms. Complete occlusion is influenced by clinical and procedural factors, supporting individualized device selection.