Stent-Assisted Coil Embolization Versus Flow Diversion in Intracranial Vertebral Artery Dissecting Aneurysms: A Systematic Review and Meta-Analysis.

INTRODUCTION

Intracranial vertebral artery dissecting aneurysms (IVADAs) represent a rare but challenging condition associated with high morbidity and mortality. In the therapeutic landscape, endovascular interventions such as Flow Diversion (FD) and Stent-Assisted Coiling (SAC) are widely used for the management of IVADAs. The aim of this systematic review and meta-analysis is to compare the clinical outcomes and complications associated with FD and SAC techniques in the endovascular management of IVADAs.

METHODS

We systematically searched PubMed, Embase, Web of Science and Scopus from inception to December 2024. This meta-analysis included retrospective cohort studies comparing flow diverters versus stent-assisted coiling in patients with IVADAs. The primary outcomes included in-stent stenosis, complete occlusion rates, and modified Rankin Scale (mRS) scores. Risk of bias was assessed using the ROBINS-I tool for non-randomized studies. Statistical analyses were conducted using R software (version 4.4.0), with risk ratios (RR) and 95% confidence intervals (CI) calculated using the Mantel-Haenszel method. Heterogeneity was assessed using Cochran's Q test and I statistics, with an I > 40% considered significant. A leave-one-out analysis was performed to evaluate the influence of individual studies on the pooled estimates.

RESULTS

A total of seven non-randomized studies were included in the meta-analysis comprising 649 patients with IVADAs. Long-term complete occlusion rates were similar between FD and SAC (RR 0.99; 95% CI 0.89-1.10; I = 0%). Favorable functional outcomes were marginally higher with FD (RR 1.04; 95% CI 1.00-1.10; I = 0%). Recurrence (RR 0.36; 95% CI 0.13-1.01; I = 0%) and retreatment rates (RR 0.44; 95% CI 0.16-1.17; I = 0%) were not significantly different between groups. In terms of safety outcomes, in-stent stenosis rates (RR 1.17; 95% CI 0.47-2.91; I = 0%) and complication rates (RR 0.74; 95% CI 0.40-1.35; I = 0%) were not statistically significantly different. Risk of bias assessment indicated an overall moderate risk across studies, with no study classified as having a serious risk of bias.

CONCLUSION

In this meta-analysis, FD and SAC demonstrated comparable efficacy and safety profiles in the treatment of IVADAs, with no significant differences in long-term complete occlusion, recurrence, retreatment, in-stent stenosis, or complication rates. In this context, FD is a promising technique to treat IVADAs.