Comparison of antithrombogenic coated and uncoated flow diverters in ruptured and unruptured cerebral aneurysms

Abstract

Background and purpose: Flow diversion has become a key treatment option for complex intracranial aneurysms. Recent advancements include coated flow diverters (FDs), designed to potentially reduce the need for dual antiplatelet therapy, thereby removing the associated secondary risks while maintaining patency and low complication rates. Comparing coated and uncoated FDs may offer insights into long-term outcomes and treatment optimization.

Method: In this retrospective single-center study, we investigated the data of 21 consecutive patients with cerebral aneurysms, treated between 2021 and 2023 with the coated Derivo 2heal Embolization Device and the uncoated Derivo Embolization Device (both Acandis). We described the procedure and analyzed clinical and radiological data, along with long-term outcomes after 18 months of follow-up.

Results: Nine patients (42.9%) had incidental, while 12 (57.1%) had symptomatic aneurysms, including 10 with World Federation of Neurosurgical Societies classification IV subarachnoid hemorrhages. Aneurysm locations included mostly the internal carotid (n = 9) and the vertebral artery (n = 7). All FDs were successfully deployed: 11 patients received the coated and 10 the uncoated device. After 18 months, 73.3% of patients had favorable outcomes (modified Rankin Score 0-2). One coated FD occluded asymptomatically after 6 months, and one uncoated FD occluded immediately but could be recanalized.

Conclusions: We observed favorable occlusion rates for both coated and uncoated FDs. The role of dual antiplatelet therapy remains debated. Large multicenter studies are essential to evaluate the patency of coated compared to uncoated FDs and determine whether they can reduce thrombogenicity, potentially allowing for less or no antiplatelet therapy in emergencies.

Keywords: aneurysm; endovascular treatment; flow diverter; subarachnoid hemorrhage.

FIGURE 1

Derivo 2heal Embolization Device in an angiographic model of a saccular aneurysm. Representation of the device in an angiographic model under (a) fluoroscopy, (b) with contrast agent, and (c) using the road‐map function.

FIGURE 2

Elective treatment of an internal carotid artery aneurysm with a Derivo 2heal Embolization Device and additional coiling. The aneurysm is shown in blue in the lower half of the image, while the internal carotid artery is depicted in red. (a) After positioning the working projection, an embolization coil (white arrow) was placed into the aneurysm before the implantation of the flow diverter. (b) After probing the parent vessel using a triaxial approach, the flow diverter is advanced through an appropriate microcatheter. The white dashed arrow indicates the distal end of the guidewire of the flow diverter. (c) Using a push and pull maneuver, the flow diverter is deployed to ensure optimal wall apposition. The black dashed arrow indicates the distal end of the flow diverter, while the white dashed arrow indicates the proximal end of the flow diverter. (d) Angiographic contrast series after the complete deployment of the flow diverter. It shows unobstructed flow through the device. There is still flow within the aneurysm sac, which is expected at this stage. (e‐g) Three‐dimensional reconstructions of the saccular aneurysm and the parent vessel. These are needed to determine the appropriate size of the flow diverter and, in this case, also the size of the embolization coil.

FIGURE 3

Treatment of a ruptured aneurysm of the superior cerebellar artery (SCA) with a Derivo 2heal Embolization Device. (a) Angiographic contrast series and depiction of a fusiform aneurysm of the right SCA (white arrow). (b) After probing the parent vessel using a triaxial approach, the flow diverter is now being deployed (white dashed arrow). (c) Complete deployment of the flow diverter, showing the distal end (white dashed arrow) and the proximal end of the flow diverter (white arrow). (d) In the nonsubtracted images, the good wall apposition of the flow diverter is clearly visible, with the distal end (white dashed arrow) in the SCA and the proximal end in the basilar artery (white arrow), as well as the caliber change at the origin of the SCA (black dashed arrow). (e) Angiographic contrast series after the complete deployment of the flow diverter. It shows unobstructed flow through the device. There is still flow within the fusiform aneurysm, which is expected at this stage.