Virtual simulation for flow-diverter selection and sizing in the endovascular treatment of intracranial aneurysms: A systematic review and meta-analysis

Abstract

Background: Endovascular treatment (EVT) of intracranial aneurysms (IAs) has improved significantly with the integration of virtual simulation software (VSS) in surgical planning and device selection. Despite promising outcomes, discrepancies remain between physician and VSS recommendations. This review synthesizes evidence on (1) comparisons between VSS-chosen and physician-chosen dimensions; (2) VSS-chosen and postoperative measured dimensions; and (3) the success rate of VSS-guided device deployment.

Methods: A systematic search adhering to PRISMA guidelines was conducted in Medline, Embase, Web of Science, and Cochrane databases up to January 2024. Eligible studies included case series, cohort studies, and randomized trials assessing VSS for stent selection in IAs treatment. Mean difference (MD) and single-arm meta-analysis with 95% confidence intervals (CIs) under a random-effects model were performed for continuous and binary outcomes. Subanalyses were conducted for Sim&Size and PreSize software.

Results: Ten studies comprising 658 IAs were included. Pipeline Embolization Device was most commonly used. Findings demonstrated (1) high accuracy of VSS when comparing simulated and postoperative lengths (MD -1.7 mm; 95% CI -4.37 to 0.98 mm); (2) physician-chosen lengths overestimated compared to VSS (MD -2.11 mm; -3.43 to -0.79 mm); (3) no significant difference in physician- versus VSS-chosen diameters (MD -0.04 mm; -0.13 to 0.06 mm); and (4) high VSS-guided deployment success (96%; 93-99%) with low complications (4%). Subanalyses showed 95% and 92% deployment success rates for Sim&Size and PreSize, respectively.

Conclusion: VSS effectively estimates device length and achieves high deployment success, with low complication rates, supporting its utility in EVT planning.

Keywords: Flow-diverter; flow-diverter sizing; simulation.

Figure 1.

PRISMA flow diagram.

Figure 2.

Forest plot showing a comparison in mean length between virtual simulation software (VSS) simulation and postoperatively measurement, demonstrating a nonsignificant mean difference (MD) in five studies, comprising 315 simulations, and indicating a precise simulation when comparing the simulated length with the postoperative length.

Figure 3.

Forest plot showing a comparison in virtual simulation software (VSS) mean length and physician-chosen mean length, demonstrating a significant mean difference (MD) in four studies, comprising 293 simulations, and indicating a significant mismatch between physician-chosen length and VSS-chosen length.

Figure 4.

Forest plot showing a comparison in virtual simulation software (VSS) mean diameter and physician-chosen mean diameter, demonstrating a significant mean difference (MD) in four studies, comprising 293 simulations, and indicating a nonsignificant difference between physician-chosen diameter and VSS-chosen diameter.

Figure 5.

Forest plot showing a high rate of Successful deployment in 542 virtual simulation software (VSS)-chosen deployed devices.

Figure 6.

Sensitivity analysis for successful deployment analysis.

Figure 7.

Forest plot showing a subanalysis for Sim&Size software. A high rate of successful deployment in 224 Sim&Size-chosen deployed devices.

Figure 8.

Forest plot showing a subanalysis for PreSize software. A high rate of successful deployment in 236 PreSize-chosen deployed devices.