Treatment of ruptured intracranial aneurysms using the novel generation of flow-diverters with surface modification: A systematic review and meta-analysis

Background: Surface modification of flow diverters (FDs) has been explored as a solution for reducing thrombotic risk of these devices, without necessarily using dual antiplatelet therapy (DAPT). If effective, this could pose a promising alternative for treatment of ruptured aneurysms not amenable to other modalities. Methods: We performed a comprehensive search of PubMed, MEDLINE, and Embase databases following Preferred Reporting Items for Systematic reviews and Meta-analyzes guidelines. We included articles reporting use of surface-modified FDs for treatment of ruptured aneurysms. Demographics, subarachnoid hemorrhage (SAH) severity, aneurysm characteristics, devices used, periprocedural complications, angiographic outcomes, and mortality were extracted for sample size-based weighted analysis. Results: Six studies comprising 59 patients with 64 aneurysms were included. Mean patient age was 56.6 ± 6.3 years and 60.6% (95% confidence interval [CI], 46.7–72.9%) were women. The anterior circulation was the location in 60.4% (95%CI, 45.5–73.5%) of aneurysms; 41.8% of the aneurysms were saccular (95%CI, 29.3–55.4%), 16.7% were fusiform (95%CI, 8.3–30.8%), 29.9% were dissecting (95%CI, 12.8–55.4%), 24.4% were blood-blister (95%CI, 15.2–36.7%), and 5.7% were mycotic (95%CI, 2–15.1%). Poor SAH grade was reported in 46.9% (95%CI, 33.3–60.9%). Adjunctive coiling was used in 33.2% (95%CI, 12.4–63.6%). Periprocedural thromboembolic and hemorrhagic complications occurred in 20% (95%CI, 7.1–45.1%) and 8.8% (95%CI, 3.7–19.5%), respectively. Complete occlusion was achieved in 76.4% (95%CI, 58.1–88.3%); no retreatments during follow-up were reported. Overall mortality was 15.1% (95%CI, 7.7–27.6%). There were no differences between single antiplatelet therapy (SAPT) and DAPT regimens with respect to periprocedural thromboembolic complications (P = 0.09), hemorrhagic (P = 0.834) complications, and mortality (P = 0.312). Conclusion: Surface-modified FD treatment of ruptured aneurysms resulted in high rates of thromboembolic complications and acceptable rates of hemorrhagic complications. A considerable proportion of aneurysms were nonsaccular. Rates of complete occlusion were high and retreatment were low. Importantly, no statistically significant difference was found between SAPT and DAPT with respect to complications and mortality.