Efficacy and safety of flow diverters for the treatment of intracranial aneurysms: a systematic review and meta-analysis

Objective: To examine the efficacy and safety of multiple brands of flow diverters (FDs) in the treatment of intracranial aneurysms (IAs). Methods: PubMed, EMBASE, and Cochrane were searched for studies on FDs treatment of IAs published until April 11, 2023. The efficacy outcomes were procedural success rate, retreatment, and complete/near-complete occlusion rate. The safety outcomes were postoperative in-stent restenosis (ISR), IA rupture, mortality, cerebrovascular events, and neurogenic death. Results: 104 studies were included. The pooled procedural success rate was 99% (95% CI: 98%-99%). The pooled overall and 1-year retreatment rates were 4% (95% CI: 3%-5%) and 1% (95% CI: 0%-3%), respectively. The pooled complete occlusion and complete/near-complete occlusion rates were 73% and 85% at 6 months, and 80% and 87% at 12 months, respectively. Subgroup analyses suggested p64™ had high 6-month (79%, 95% CI: 72%-84%) and 12 months (91%, 95% CI: 82%-97%) complete occlusion rates and low rescue rates (2%, 95% CI: 0%-6%). The overall aneurysm rupture rate, all-cause mortality, and overall ISR were 1%, 2% and 5%, respectively. The 1-month rates of neurogenic death, hemorrhagic, ischemic, and thromboembolic events were 1%, 2%, 5% and 3%, respectively. Conclusion: FDs treatment for IA achieves high procedural success and occlusion rates, and the safety profile is favorable with a low incidence of IA rupture and mortality. However, these findings should be interpreted with caution due to the substantial clinical heterogeneity and the predominance of observational single-arm studies among the included literature.