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Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study
  1. Christoph J Griessenauer1,2,
  2. Alejandro Enriquez-Marulanda3,
  3. Sissi Xiang4,
  4. Tao Hong4,
  5. Hongqi Zhang4,
  6. Philipp Taussky5,
  7. Ramesh Grandhi5,
  8. Muhammad Waqas6,
  9. Vincent M Tutino6,
  10. Adnan H Siddiqui6,
  11. Elad I Levy6,
  12. Christopher S Ogilvy7,
  13. Ajith J Thomas7,
  14. Christian Ulfert8,
  15. Markus A Möhlenbruch8,
  16. Leonardo Renieri9,
  17. Nicola Limbucci9,
  18. Carmen Parra-Fariñas10,
  19. Jan-Karl Burkhardt11,
  20. Peter Kan11,
  21. Lorenzo Rinaldo12,
  22. Giuseppe Lanzino12,
  23. Waleed Brinjikji12,
  24. Julian Spears13,
  25. Erasmia Müller-Thies-Broussalis2,14,
  26. Monika Killer-Oberpfalzer2,14,
  27. Civan Islak15,
  28. Naci Kocer15,
  29. Michael Sonnberger16,
  30. Tobias Engelhorn17,
  31. Mandeep Ghuman18,
  32. Victor XD Yang18,
  33. Arsalaan Salehani19,
  34. Mark R Harrigan19,
  35. Ivan Radovanovic20,
  36. Vitor M Pereira20,
  37. Timo Krings20,
  38. Charles C Matouk21,
  39. Karen Chen22,
  40. Mohammad Ali Aziz-Sultan22,
  41. Mohammad Ghorbani23,
  42. Clemens M Schirmer1,2,
  43. Oded Goren1,
  44. Shamsher S Dalal24,
  45. Matthew J Koch25,
  46. Christopher J Stapleton25,
  47. Aman B Patel25,
  48. Thomas Finkenzeller26,
  49. Markus Holtmannspötter27,
  50. Jan Hendrik Buhk28,
  51. Paul Michael Foreman29,
  52. Marshall Cress29,
  53. Robert Hirschl29,
  54. Wolfgang Reith30,
  55. Andreas Simgen30,
  56. Hendrik Janssen31,
  57. Thomas R Marotta13,
  58. Adam A Dmytriw13,18,20
  1. 1 Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
  2. 2 Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
  3. 3 Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  4. 4 Department of Neurosurgery, Xuanwu Hospital, Beijing, China
  5. 5 Department of Neurosurgery, University of Utah Hospital, Salt Lake City, Utah, USA
  6. 6 Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  7. 7 Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  8. 8 Department of Neuroradiology, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
  9. 9 Interventional Neuroradiology, University Hospital Careggi, Firenze, Toscana, Italy
  10. 10 Radiology Department, St Michael's Hospital, Toronto, Ontario, Canada
  11. 11 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  12. 12 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
  13. 13 Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
  14. 14 Department of Neurology, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
  15. 15 Department of Radiology, Istanbul University-Cerrahpasa, Istanbul, Turkey
  16. 16 Department of Neuroradiology, Johannes Kepler Universitat Linz, Linz, Austria
  17. 17 Department of Neuroradiology, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, Erlangen, Bayern, Germany
  18. 18 Neuroradiology & Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
  19. 19 Department of Neurosurgery, UAB Hospital, Birmingham, Alabama, USA
  20. 20 Interventional Neuroradiology & Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
  21. 21 Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  22. 22 Neurointerventional Radiology and Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
  23. 23 Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
  24. 24 Department of Radiology, Geisinger Health System, Danville, Pennsylvania, USA
  25. 25 Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  26. 26 Klinikum Nürnberg, Nurnberg, Bayern, Germany
  27. 27 Department of Neuroradiology, Rigshospitalet, Copenhagen, Denmark
  28. 28 Department of Diagnostic and Interventional Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
  29. 29 Orlando Health Corp, Orlando, Florida, USA
  30. 30 Department of Neuroradiology, Universitatsklinikum des Saarlandes und Medizinische Fakultat der Universitat des Saarlandes, Homburg, Germany
  31. 31 Department of Neuroradiology, Nuremberg Hospital, Nurnberg, Bayern, Germany
  1. Correspondence to Dr Christoph J Griessenauer, Department of Neurosurgery, Geisinger, 100 N Academy Ave, Danville, PA 17821, USA; christoph.griessenauer{at}


Background Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce.

Objective To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms.

Methods Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome.

Results A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04).

Conclusion Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.

  • flow diverter
  • aneurysm
  • embolic
  • intervention
  • posterior fossa

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  • Contributorship Statement All authors included on a paper fulfill all four criteria of authorship, including substantial contributions to the conception or design of the work, the acquisition, analysis, and interpretation of data for the work, drafting the work or revising it critically for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Conception and design: CJG, AE-M, AAD. Acquisition of data: all authors. Analysis and interpretation of data: CJG, AE-M, AAD. Drafting the article: CJG. Critical revision of the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: CJG. Statistical analysis: CJG, AE-M. Administrative/technical/material support: all authors. Study supervision: CJG, AE-M, AAD.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Ajith Thomas: DSMB SCENT trial by STRYKER. Funds paid to institution.

    Ramesh Grandhi: Consultant for Medtronic neurovascular, BALT neurovascular and Cerenovus.

    Christoph Griessenauer: Consultant for Stryker and received research funding from Medtronic.

    Naci Kocer: Consultant and proctoring agreement with MicroVention.

    Philipp Taussky:Reply: Consultant for Medtronic, Stryker, Cerenovus.

    Peter Kan: Consultant for Stryker, Medtronic, MicroVention, and Cerenovus.

    Vincent Tutino: Co-founder of Neurovascular Diagnostics, Inc.

    Monika Killer: Research grant from MicroVention/Terumo.

    Waleed Brinjikji: Microvention and Cerenovus consultant.

    Tom Marotta: Medtronic proctoring.

    Timo Krings: Consultant for Stryker, Medtronic, Penumbra, Cerenovus. stockholder in Marblehead Inc, royalties from Thieme.

    Clemens Schirmer: Research Support from Penumbra. Shareholder in Neurotechnology Investors.

    Giuseppe Lanzino: Consultant for Superior Medical Editing and Nested Knowledge.

    Christian Ulfert: Consulting fees from Johnson & Johnson.

    Charles Matouk: Consultant for Medtronic, Penumbra, Silk Road Medical

    Markus Mohlenbruch: Consultant for Medtronic, MicroVention, Stryker. Grants/grants pending: Balt (money paid to the institution), MicroVention (money paid to the institution). Payment for lectures includings service on speakers bureaus: Medtronic, MicroVention, and Stryker.

    Marshall Cress: Consulting for Cannon and Cerenovus.

    None related to this study and none are declared for the reminder of the authors.

  • Patient consent for publication Not required.

  • Ethics Approval The study was performed in compliance with the World Medical Association’s Declaration of Helsinki. The study protocol was approved by the local ethics committees of Erlanger, Hamburg, Heidelberg, Istanbul, Linz, Nurnberg, Salzburg, Homburg, Sunnybrook, Beth Israel Deaconess, Geisinger, Toronto Western, St. Michael’s, Yale, Buffalo, Florence, University of Alabama, Firoozgar, Baylor, Brigham and Women’s, Mayo Clinic, University of Utah, Orlando Health, Massachusetts General and Xuanwu.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request and after execution of required necessary data use agreements.