Flow diverter braid deformation following treatment of cerebral aneurysms: incidence, clinical relevance, and potential risk factors.

Background: Although flow diverters (FDs) have benefited from several technical improvements, recently concerns have arisen regarding the braid stability after implantation. Thus, we investigated frequency, predictive factors, and clinical impact of the phenomenon of FD braid deformation (FDBD).
Methods: Consecutive intracranial aneurysms (IAs) treated with various FDs, between January 2018 and July 2023, were reviewed to identify FDBD (defined as the deformation of a FD without any external force applied to it). Patient, aneurysm, procedural, and FD characteristics were retrieved and analyzed using univariate and multivariable analyses. Morbidity is defined as a score of +1 in the modified Rankin Scale at 3 months.
Results: In total, 245 FD procedures (271 FDs implanted; 25 multiple IAs treated with 1 FD) in 228 patients; FDBD was observed in 36/245 cases (14.7%), mainly at follow-up angiography (32/36, 88.9%); fish-mouthing was the most frequent FDBD. Morbidity was related to fish-mouthing and braid collapse and was significantly higher in the FDBD group after retreatment (p=0.04). Drawn filled tubing with platinum (DFT) (adjusted odds ratio (aOR)=7.0, 95% CI 3.0 to 17.5; p<0.001) and FD diameter (aOR=2.2, 95% CI 1.3 to 4.1; p<0.01) were identified as independent predictors of FDBD. The metal alloy composing the FD (p=0.13) and coated surfaces were not significantly associated with FDBD (p=0.54 in multivariable analysis).
Conclusions: FDBD is a frequent phenomenon observed in about 15% of cases, and it was responsible for higher morbidity. Only FD characteristics (DFT and FD diameter) were independent determinants of FDBD. Future research should focus on the impact of novel braid configurations and materials on braid stability.
Competing Interests: Competing interests: JCo received research grants from Medtronic, Phenox, and Microvention; and received honoraria for lectures from Balt. DFK received research support from Cerenovus, Sensome, Neurogami Medical, Insera Therapeutics, Medtronic, Microvention, Balt, Monarch Biosciences, Brainomix, MiVi, Stryker, and National Institutes of Health (NIH); royalties from Medtronic; is on the Data Safety Monitoring Board (DSMB) of NoNO Inc. and Vesalio; is a stockholder in Nested Knowledge, Superior Medical Experts, Marblehead Medical, and Conway Medical. JCa received honoraria from Balt, Cerenovus, and Medtronic for lectures. LS is a consultant for Microvention, Balt, Phenox, Stryker, and Medtronic; DSMB or Advisory Board for CHOICE Study, INSPIRE Study, CLEVER study, and COATING study; grant or contract from Philips with institution.
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