Comparative meta-analysis of endovascular strategies for intracranial dissecting aneurysms: Flow diverters versus stents with or without coiling

Abstract

Background: Intracranial dissecting aneurysms present a challenging subset linked to considerable morbidity and mortality, necessitating effective therapeutic strategies to prevent complications. Traditional treatments face technical limitations, while emerging endovascular modalities like stent-assisted coiling, multiple stenting, and flow-diverting devices (FDDs) offer promise in reducing periprocedural risks and enhancing patient outcomes. The aim of this study is to compare the safety and efficacy outcomes of endovascular treatment for intracranial dissecting aneurysms using FDDs versus stents (with or without coiling).

Methods: A systematic review and meta-analysis were conducted following established guidelines. The search included PubMed, Scopus, Web of Science, and Embase databases up to July 30, 2023. Eligible studies reporting outcomes of interest in both FDD and stent-treated groups were included, and the data was extracted and analyzed using STATA software.

Results: Six studies were analyzed, involving 131 patients in the FDD group and 199 patients in the stent group. The pooled rates for favorable functional outcomes (86.8% vs. 86%), mortality (3.9% vs. 6%), adequate occlusion (79.7% vs. 86.3%), aneurysm recurrence (1.3% vs. 13.3%), in-stent stenosis/thrombosis (7% vs. 6.9%), ischemic events/infarctions (6.7% vs. 7.8%), retreatment (7% vs. 8.6%), and technical success (100% vs. 98.7%) were comparable in individuals treated with FDDs and stents (p > 0.05 in all cases). Additionally, complete occlusion rates were not significantly different between FDD (62.7%) and stent-treated patients (75.2%) (p = 0.06). However, after excluding one study in a leave-one-out analysis of the random effects meta-analysis, a significant difference in the pooled rates of this outcome was observed between the FDD (59.2%) and stent (75.2%) groups (p = 0.034).

Conclusion: FDDs present a promising approach for the treatment of intracranial dissecting aneurysms, yielding outcomes that are roughly comparable to stent-based methods. However, the absence of randomized trials and data limitations highlight the need for further research to enhance treatment strategies.

Keywords: Flow diverters; aneurysm; dissection; efficacy; safety; stents.

Figure 1.

PRISMA flow diagram showing the review process. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2.

Forest plot of the random-effects meta-analysis for reported favorable functional outcome rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.

Figure 3.

Forest plot of the random-effects meta-analysis for reported mortality rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.

Figure 4.

Forest plot of the random-effects meta-analysis for reported complete occlusion rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.

Figure 5.

Forest plot of the leave-one-out analysis of the random-effects meta-analysis for reported complete occlusion rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.

Figure 6.

Forest plot of the random-effects meta-analysis for reported recurrence rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.

Figure 7.

Forest plot of the leave-one-out analysis of the random-effects meta-analysis for reported recurrence rates in patients with dissecting aneurysms undergoing endovascular treatment with flow diverter devices compared to stents. CI: confidence interval; FD: flow diverter; FU: follow up; M: months; mRS: modified Rankin score; OR: odds ratio.