Comparative safety, efficacy, and predictors of complete occlusion of flow diverter devices in the treatment of unruptured distal anterior cerebral artery aneurysms

Background: Flow diverters (FDs) are increasingly used for cerebral aneurysms, including distal anterior cerebral artery (DACA) aneurysms, but comparative data between devices in this challenging location are limited. Objective: To compare the safety and efficacy of Pipeline, Silk Vista Baby (SVB), and FRED Jr. FDs for unruptured DACA aneurysms and identify predictors of complete occlusion. Methods: We retrospectively analyzed 166 patients treated with FDs at 39 centers in 14 countries (2018–2022) from the CRETA registry. Outcomes included aneurysm occlusion (O’Kelly–Marotta [OKM] scale), complications, retreatment, modified Rankin Scale (mRS) scores, and independent predictors of complete occlusion using multivariable Cox regression. Results: Aneurysms were predominantly saccular and located on the pericallosal artery. Complete occlusion (OKM D) was achieved in 73%, and neck remnants (OKM C) in 12%, with no differences across devices. Ischemic complications occurred in 11% (mostly asymptomatic), hemorrhagic complications in 5%, and in-stent stenosis in 17%. Retreatment was performed in 1.3%. At last follow-up, 98% had mRS ≤ 2. Independent predictors of complete occlusion were female sex (HR 1.85), asymptomatic presentation (HR 1.79), smaller aneurysm neck (HR 0.83/mm), radial access (HR 2.20), and aspirin plus ticagrelor therapy (HR 1.84); device type was not predictive. Conclusion: Pipeline, SVB, and FRED Jr. FDs show similar safety and efficacy for unruptured DACA aneurysms. Complete occlusion is influenced by clinical and procedural factors, supporting individualized device selection.