Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications—a retrospective data analysis



We report the experiences of 25 Italian centers, analyzing intra- and periprocedural complications of endovascular treatment of intracranial aneurysms using Silk (Balt Extrusion, Montmorency, France) and pipeline embolization devices (EV3 Inc, Irvine California).


Two hundred seventy-three patients with 295 cerebral aneurysms, enrolled in 25 centers in Italy and treated with the new flow-diverter devices, were evaluated; 142 patients were treated with Silk and 130 with pipeline (in one case, both devices were used). In 14 (5.2 %) cases devices were used with coils. Aneurysm size was >15 mm in 46.9 %, 5–15 mm in 42.2 %, and <5 mm in 10.8 %. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 163 cases (55.2 %), cavernous ICA in 76 (25.7 %), middle cerebral artery in 11 (3.7 %), PCoA in 6 (2 %), and ACoA in 2 (0.7 %); the vertebrobasilar system accounted for 32 cases (10.8 %) and PCA in 5 (1.7 %).


Technical adverse events occurred with 59 patients (21.6 %); 5 patients died after ischemic events, 10 to hemorrhagic complications, and 1 from external ventricular drain positioning. At 1 month, morbidity and mortality rates were 3.7 % and 5.9 %, respectively


Our retrospective study confirms that morbidity and mortality rates in treatment with FDD of unruptured wide-neck or untreatable cerebral aneurysms do not differ from those reported in the largest series.

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Fig. 1


  1. 1.

    Augsburger L, Farhat M, Reymond P, Fonck E, Kulcsar Z, Stergiopulos N, Rufenacht DA (2009) Effect of flow diverter porosity on intraaneurysmal blood flow. Klin Neuroradiol 19(3):204–214. doi:10.1007/s00062-009-9005-0

    PubMed  Article  Google Scholar 

  2. 2.

    Byrne JV, Beltechi R, Yarnold JA, Birks J, Kamran M (2010) Early experience in the treatment of intra-cranial aneurysms by endovascular flow diversion: a multicentre prospective study. PLoS One 5 (9). doi:10.1371/journal.pone.0012492

  3. 3.

    Campi A, Ramzi N, Molyneux AJ, Summers PE, Kerr RS, Sneade M, Yarnold JA, Rischmiller J, Byrne JV (2007) Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT). Stroke 38(5):1538–1544. doi:10.1161/STROKEAHA.106.466987

    PubMed  Article  Google Scholar 

  4. 4.

    Fiorella D, Albuquerque F, Gonzalez F, McDougall CG, Nelson PK (2010) Reconstruction of the right anterior circulation with the Pipeline embolization device to achieve treatment of a progressively symptomatic, large carotid aneurysm. J Neurointerv Surg 2(1):31–37. doi:10.1136/jnis.2009.000554

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Fiorella D, Albuquerque FC, Deshmukh VR, McDougall CG (2005) Usefulness of the Neuroform stent for the treatment of cerebral aneurysms: results at initial (3-6-mo) follow-up. Neurosurgery 56(6):1191–1201, discussion 1201-1192

    PubMed  Article  Google Scholar 

  6. 6.

    Fiorella D, Albuquerque FC, Woo H, Rasmussen PA, Masaryk TJ, McDougall CG (2010) Neuroform stent assisted aneurysm treatment: evolving treatment strategies, complications and results of long term follow-up. J Neurointerv Surg 2(1):16–22. doi:10.1136/jnis.2009.000521

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Fiorella D, Kelly ME, Albuquerque FC, Nelson PK (2009) Curative reconstruction of a giant midbasilar trunk aneurysm with the pipeline embolization device. Neurosurgery 64(2):212–217. doi:10.1227/01.NEU.0000337576.98984.E4, discussion 217

    PubMed  Article  Google Scholar 

  8. 8.

    Fiorella D, Lylyk P, Szikora I, Kelly ME, Albuquerque FC, McDougall CG, Nelson PK (2009) Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg 1(1):56–65. doi:10.1136/jnis.2009.000083

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Fiorella D, Woo HH, Albuquerque FC, Nelson PK (2008) Definitive reconstruction of circumferential, fusiform intracranial aneurysms with the pipeline embolization device. Neurosurgery 62(5):1115–1120. doi:10.1227/01.neu.0000325873.44881, discussion 1120-1111

    PubMed  Article  Google Scholar 

  10. 10.

    Johnston SC, Dowd CF, Higashida RT, Lawton MT, Duckwiler GR, Gress DR (2008) Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARAT) study. Stroke 39(1):120–125. doi:10.1161/STROKEAHA.107.495747

    PubMed  Article  Google Scholar 

  11. 11.

    Kallmes DF, Ding YH, Dai D, Kadirvel R, Lewis DA, Cloft HJ (2007) A new endoluminal, flow-disrupting device for treatment of saccular aneurysms. Stroke 38(8):2346–2352. doi:10.1161/STROKEAHA.106.479576

    PubMed  Article  Google Scholar 

  12. 12.

    Kis B, Weber W, Gotz F, Becker H, Berlit P, Kuhne D (2007) Endovascular treatment of cerebral aneurysms using the Leo stent: long term follow-up and expansion of indications. Clin Neuradiol 17:167–179

    Google Scholar 

  13. 13.

    Kulcsar Z, Houdart E, Bonafe A, Parker G, Millar J, Goddard AJ, Renowden S, Gal G, Turowski B, Mitchell K, Gray F, Rodriguez M, van den Berg R, Gruber A, Desal H, Wanke I, Rufenacht DA (2011) Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol 32(1):20–25. doi:10.3174/ajnr.A2370

    PubMed  CAS  Google Scholar 

  14. 14.

    Leonardi M, Cirillo L, Toni F, Dall'olio M, Princiotta C, Stafa A, Simonetti L, Agati R (2011) Treatment of intracranial aneurysms using flow-diverting silk stents (BALT): a single centre experience. Interv Neuroradiol 17(3):306–315. doi:IN.v17.i3

    PubMed  CAS  Google Scholar 

  15. 15.

    Lubicz B, Collignon L, Raphaeli G, Pruvo JP, Bruneau M, De Witte O, Leclerc X (2010) Flow-diverter stent for the endovascular treatment of intracranial aneurysms: a prospective study in 29 patients with 34 aneurysms. Stroke 41(10):2247–2253. doi:10.1161/STROKEAHA.110.589911

    PubMed  Article  Google Scholar 

  16. 16.

    Lylyk P, Ferrario A, Pasbon B, Miranda C, Doroszuk G (2005) Buenos Aires experience with the Neuroform self-expanding stent for the treatment of intracranial aneurysms. J Neurosurg 102(2):235–241. doi:10.3171/jns.2005.102.2.0235

    PubMed  Article  Google Scholar 

  17. 17.

    Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, Berez AL, Tran Q, Nelson PK, Fiorella D (2009) Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64(4):632–642. doi:10.1227/01.NEU.0000339109.98070.65, discussion 642-633; quiz N6

    PubMed  Article  Google Scholar 

  18. 18.

    Mocco J, Snyder KV, Albuquerque FC, Bendok BR, Alan SB, Carpenter JS, Fiorella DJ, Hoh BL, Howington JU, Jankowitz BT, Liebman KM, Rai AT, Rodriguez-Mercado R, Siddiqui AH, Veznedaroglu E, Hopkins LN, Levy EI (2009) Treatment of intracranial aneurysms with the Enterprise stent: a multicenter registry. J Neurosurg 110(1):35–39. doi:10.3171/2008.7.JNS08322

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366(9488):809–817. doi:10.1016/S0140-6736(05)67214-5

    PubMed  Article  Google Scholar 

  20. 20.

    Mustafa W, Kadziolka K, Anxionnat R, Pierot L (2010) Direct carotid-cavernous fistula following intracavernous carotid aneurysm treatment with a flow-diverter stent. A case report Interv Neuroradiol 16(4):447–450. doi:IN.v16.i4

    CAS  Google Scholar 

  21. 21.

    Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D (2011) The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 32(1):34–40. doi:10.3174/ajnr.A2421

    PubMed  CAS  Google Scholar 

  22. 22.

    Piotin M, Blanc R, Spelle L, Mounayer C, Piantino R, Schmidt PJ, Moret J (2010) Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke 41(1):110–115. doi:10.1161/STROKEAHA.109.558114

    PubMed  Article  Google Scholar 

  23. 23.

    Pumar JM, Garcia-Dorrego R, Nieto A, Vazquez-Herrero F, Blanco-Ulla M, Vazquez-Martin A (2010) Vascular reconstruction of a fusiform basilar aneurysm with the Silk embolization system. J Neurointerv Surg 2(3):242–244. doi:10.1136/jnis.2010.002725

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Sedat J, Chau Y, Mondot L, Vargas J, Szapiro J, Lonjon M (2009) Endovascular occlusion of intracranial wide-necked aneurysms with stenting (Neuroform) and coiling: mid-term and long-term results. Neuroradiology 51(6):401–409. doi:10.1007/s00234-009-0502-2

    PubMed  Article  Google Scholar 

  25. 25.

    Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK (2012) Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. AJNR Am J Neuroradiol 33(1):159–163. doi:10.3174/ajnr.A2719

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, Berez A, Nelson PK (2010) Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol 31(6):1139–1147. doi:10.3174/ajnr.A2023

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Turowski B, Macht S, Kulcsar Z, Hanggi D, Stummer W (2011) Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts? Neuroradiology 53(1):37–41. doi:10.1007/s00234-010-0676-7

    PubMed  Article  Google Scholar 

  28. 28.

    van Houwelingen HC, Arends LR, Stijnen T (2002) Advanced methods in meta-analysis: multivariate approach and meta-regression. Stat Med 21(4):589–624. doi:10.1002/sim

    PubMed  Article  Google Scholar 

  29. 29.

    Wakhloo AK, Deleo MJ 3rd, Brown MM (2009) Advances in interventional neuroradiology. Stroke 40(5):e305–e312. doi:10.1161/STROKEAHA.109.548438

    PubMed  Article  Google Scholar 

  30. 30.

    Yang X, Wu Z, Mu S, Li Y, Lv M (2008) Endovascular treatment of giant and large intracranial aneurysms using the neuroform stent-assisted coil placement. Neurol Res 30(6):598–602. doi:10.1179/174313208X319017

    PubMed  Article  Google Scholar 

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Conflict of interest

F. Briganti, E. Boccardi, M. Isalberti, N.P. Nuzzi, and L.P. Valvassori Bolgè serve as proctors for EV3 and receive modest remuneration. E. Boccardi and L.P Valvassori Bolgè serve as proctors for BALT and receive modest remuneration. E.C Cagliari serves as a proctor for EV3 without remuneration.

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Correspondence to Francesco Briganti.

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Briganti, F., Napoli, M., Tortora, F. et al. Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications—a retrospective data analysis. Neuroradiology 54, 1145–1152 (2012).

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  • Flow diverter device
  • Pipeline embolization device
  • Silk embolization device
  • Intracranial aneurysms
  • Endovascular treatment