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Predictors of aneurysm occlusion after treatment with flow diverters: a systematic literature review
  1. Lukas Meyer1,
  2. Christian Paul Stracke1,2,
  3. Maxim Bester1,
  4. Kevin M Kallmes3,
  5. Kamil Zeleňák4,
  6. Aymeric Rouchaud5,
  7. Mario Martínez-Galdámez6,
  8. Pascal Jabbour7,
  9. Thanh N Nguyen8,
  10. Adnan H Siddiqui9,
  11. Jens Fiehler1,
  12. Susanne Gellissen1
  1. 1 Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2 Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
  3. 3 Nested Knowledge, Inc, Saint Paul, Minnesota, USA
  4. 4 Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
  5. 5 Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
  6. 6 Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
  7. 7 Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  8. 8 Departments of Radiology and Neurology, Boston Medical Center, Boston, Massachusetts, USA
  9. 9 Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
  1. Correspondence to Dr Lukas Meyer, Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany; lu.meyer{at}


Background Flow diverters (FDs) have become an integral part of treatment for brain aneurysms.

Aim To summarize available evidence of factors associated with aneurysm occlusion (AO) after treatment with a FD.

Methods References were identified using the Nested Knowledge AutoLit semi-automated review platform between January 1, 2008 and August 26, 2022. The review focuses on preprocedural and postprocedural factors associated with AO identified in logistic regression analysis. Studies were included if they met the inclusion criteria of study details (ie, study design, sample size, location, (pre)treatment aneurysm details). Evidence levels were classified by variability and significancy across studies (eg, low variability ≥5 studies and significance in ≥60% throughout reports).

Results Overall, 2.03% (95% CI 1.22 to 2.82; 24/1184) of screened studies met the inclusion criteria for predictors of AO based on logistic regression analysis. Predictors of AO with low variability in multivariable logistic regression analysis included aneurysm characteristics (aneurysm diameter), particularly complexity (absence of branch involvement) and younger patient age. Predictors of moderate evidence for AO included aneurysm characteristics (neck width), patient characteristics (absence of hypertension), procedural (adjunctive coiling) and post-deployment variables (longer follow-up; direct postprocedural satisfactory occlusion). Variables with a high variability in predicting AO following FD treatment were gender, FD as re-treatment strategy, and aneurysm morphology (eg, fusiform or blister).

Conclusion Evidence of predictors for AO after FD treatment is sparse. Current literature suggests that absence of branch involvement, younger age, and aneurysm diameter have the highest impact on AO following FD treatment. Large studies investigating high-quality data with well-defined inclusion criteria are needed for greater insight into FD effectiveness.

  • Flow Diverter
  • Aneurysm

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • X @MeyerL_MD, @ZelenakKamil, @aymeric87, @Doctorgaldamez, @PascalJabbourMD, @NguyenThanhMD, @_AdnanSiddiqui, @Fie0815

  • Contributors LM, SG, and JF: acquisition of data, data analysis, critical review of manuscript, approval of manuscript. CPS, AHS, PJ, MB, KMK, KZ, TNN, AR, and MM-G: critical review of manuscript, approval of manuscript. LM and SG: acquisition of data, data analysis, drafting of manuscript, critical review of manuscript, approval of manuscript, guarantors of the study.

  • 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 JF: research support from the German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-/Förderbank (IFB), Medtronic, Microvention, Philips, Stryker; consultancy appointments; Acandis, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medtronic, Medina, Microvention, Penumbra, Route92, Stryker, Transverse Medical; stock holdings for Tegus, JNIS associate editor. KMK: works for, and holds equity in, Nested Knowledge, works for Conway Medical, and holds equity in Piraeus Medical and Superior Medical Experts. TNN: reports research support from Medtronic and SVIN. KZ: support under the operational program Integrated Infrastructure for the project: TENSION—complementary project, IMTS: 313011W875, co-financed by the European Regional Development Fund. AR: consultant for Balt and Medtronic. LM: received financial compensation as a speaker for Balt Prime. MM-G: JNIS associate editor. The other authors report no conflict of interest.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.