Silk Vista baby for the Treatment of Distal Anterior Cerebral Artery Aneurysms

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Dmytriw, Eimad Shotar, and 62 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6613699/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jul, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Abstract Purpose: Treating small-caliber vessel aneurysms with flow diverters presents challenges due to narrow luminal diameters and tortuous vasculature, which make navigation and deployment of conventional devices using standard microcatheters more difficult. The Silk Vista Baby (SVB, Balt, Montmorency, France) flow diverter was developed to treat intracranial aneurysms located in smaller vessels or more distal lesions and is compatible with 0.017″ microcatheters. We present the largest multicenter analysis to date evaluating the outcomes of SVB use in unruptured distal anterior cerebral artery (DACA) aneurysms. Methods: Retrospective data from 20 centers were reviewed for patients with unruptured DACA aneurysms treated with SVB. The following were recorded: demographic information, clinical presentation, radiographic characteristics, procedural complications, and outcomes. Results: Seventy-nine patients (79 DACA aneurysms) were treated between January 2018 and December 2022; 59 were female (74.7%), and the median age was 61 years (IQR 53–67). Most aneurysms were saccular (91.7%), and 61.9% involved a branch. The median parent vessel diameter was 1.9 mm (IQR 1.7–2.1). A single stent was implanted in 97.5% of cases; 2.5% required two stents. The median imaging follow-up was 12 months (IQR 9.5–24). At the last follow-up, 76% of aneurysms showed complete or near-complete occlusion (O’Kelly–Marotta scale C or D). Overall, thromboembolic or hemorrhagic complications occurred in 14% of patients, with only 2 cases being symptomatic; mortality rate was 0%. The retreatment rate was 1.3%. Conclusion: In this multicenter series, the SVB flow diverter emerged as a safe and effective treatment option for unruptured DACA aneurysms. Figures Figure 1 INTRODUCTION Flow diverters (FDs) were initially approved for large, complex, unruptured aneurysms located in the internal carotid artery (ICA). Over time, their use has been extended to smaller aneurysms (less than 10 mm) and those involving the ICA terminus [ 1 , 2 ]. FDs have demonstrated excellent occlusion rates—75–95%—with higher rates of success for smaller aneurysms and after one year of follow-up [ 3 , 4 ]. Additional studies have confirmed their safety and efficacy in managing small- and medium-sized aneurysms [ 5 ], as well as their suitability for ruptured cases [ 6 ]. Conventional coiling of distal anterior cerebral artery aneurysms (DACA) has been reported to carry a higher risk of procedure-related rupture than non-DACA aneurysms, potentially because of the more distal location and consequently less control over coil and microcatheter deployment [ 7 ]. As a result, exploring alternative endovascular techniques—particularly flow diverters—has gained traction. The off-label use of FDs for distal aneurysms remains somewhat controversial, and data on long-term outcomes for aneurysms situated at bifurcations or beyond the circle of Willis (e.g., DACA or pericallosal artery aneurysms) remain limited [ 8 , 9 ]. The Silk Vista Baby (SVB) FD (Balt, Montmorency, France) is a nitinol stent designed for small vessels with diameters of 1.5–3.5 mm. It is delivered via a 0.017-inch microcatheter and incorporates platinum into its nitinol structure, enhancing radiopacity, navigability, and safety [ 10 , 11 ]. The purpose of this study was to analyze radiological and clinical outcomes in patients with unruptured aneurysms treated using SVB, based on data from an international multicenter consortium. METHODS Patient Population This analysis included patients with unruptured DACA aneurysms treated with SVB from the CRETA Consortium [ 8 ](Fig. 1 ). They underwent endovascular treatment across multiple academic centers in North and South America, Europe, and Asia. Data were gathered on patient demographics, aneurysm characteristics, procedural details, complications, and clinical/radiographic outcomes. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. This study is part of a nonprofit research protocol approved by the ethics committee of the coordinating center (XXXXX). Outcomes and Complications The primary endpoints were aneurysm occlusion at last follow-up and the incidence of both hemorrhagic and thromboembolic complications. Radiological outcomes were measured through digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA), and graded using the O’Kelly–Marotta (OKM) scale. Secondary endpoints included technical success, procedural complications, retreatment rates, imaging-based assessment of covered branches, and functional outcomes at the last follow-up. Functional outcomes were assessed with the modified Rankin Scale (mRS). Thromboembolic complications were recorded from the day of the procedure through the last follow-up. Intra-procedural thromboembolic events were identified by DSA evidence of thrombus formation, delayed vessel filling, or complete vascular occlusion. Post-procedural events were identified based on clinical symptoms or imaging findings (CTA, MRI, or non-contrast CT). Only ischemic strokes in the treated vessel territory were included, and ischemic complications were classified as symptomatic if they resulted in patient-reported symptoms or clinical signs of transient or persistent ischemia. Complications persisting at three months were deemed permanent. Hemorrhagic complications were identified either intraoperatively (via contrast extravasation on DSA) or through post-procedure imaging. Hemorrhages were included if they occurred from the time of the procedure until the last follow-up, and were classified as symptomatic if the patient reported related symptoms or showed neurological signs. Unlike ischemic events, hemorrhagic complications included all vascular territories. Statistical Analysis Descriptive analysis was performed in STATA 17.0 (StataCorp, Texas, USA). No inferential statistics were conducted. Categorical variables are shown as counts (percentages), and continuous variables as medians (IQR). RESULTS Baseline Patient and Aneurysm Characteristics Seventy-nine patients (median age: 61 years, IQR 53–67) with 79 DACA aneurysms treated with a flow diverter (FD) (Fig. 1 ) were included from 20 centers. The majority (74.7%) were female ( Table 1 ). On admission, all patients were functionally independent (mRS 0–2). Twenty-two patients (27.8%) had a previous subarachnoid hemorrhage (SAH), of which 18 (22.8%) were from the same DACA aneurysm. These 18 patients later underwent FD retreatment because of aneurysm recurrence. A total of 22 patients (27.8%) had already undergone an endovascular procedure: 19 had coiling and 3 underwent another form of endovascular intervention. Of the 79 aneurysms, 71 (89.9%) were saccular and 8 (10.1%) were fusiform (Table 2). The median parent vessel diameter was 1.9 mm (IQR 1.7–2.1). Fifty-two aneurysms (65.8%) had an arterial branch originating from the aneurysm. Treatment Characteristics and Medications In 64 (81%) cases, the procedure was performed via femoral access; the remaining 15 (19%) were done via radial access. General anesthesia was used in all cases. A triaxial system was used in 70 procedures (88.6%) and a biaxial system in 9 (11.4%). A single FD was deployed in 77 cases (97.5%), while 2 stents were required in 2 cases (2.5%). Adjunctive coiling was performed in 4 aneurysms (5%), typically those with an irregular morphology and with at least one dimension (height, width, or depth) of 6.7 mm or larger ( Table 2 ). All patients received an antiplatelet regimen prior to the procedure. The most common regimen was aspirin plus clopidogrel (70.9%, 56 patients). Aspirin plus ticagrelor (21.5%, 17 patients) or other combinations (e.g., aspirin plus prasugrel, aspirin plus ticlopidine) were used in the remaining patients (7.6%). Platelet function testing was performed in 42 of 79 patients (53.1%), most commonly via light transmission platelet aggregation (39 of 42). Clopidogrel resistance was found in 13 of these 42 patients (31%); in these cases, clopidogrel was replaced with ticagrelor before the endovascular procedure. Clinical and Imaging Outcomes Immediately after the procedure, complete angiographic occlusion (OKM D) was achieved in 8 aneurysms (10.1%), while adequate occlusion (OKM C or D) was observed in 14 (17.7%). At the last radiological follow-up, 55 cases (69.6%) had complete occlusion (OKM D), and 60 (76%) achieved adequate occlusion (OKM C or D). The median imaging follow-up period was 12 months (IQR 9.5–24), with DSA in 46 patients (58.2%), MRA in 18 (22.8%), and CTA in 10 (12.7%). In-stent stenosis was observed in 16 cases (20.3%), attributed entirely to intimal hyperplasia. The median clinical follow-up period was 13 months (IQR 6.5–25); five patients (6.3%) were lost to follow-up. At the last follow-up, the mRS score was 0 in 79.7% of patients, 1 in 7.6%, and 2 in 3.8%; one patient (1.3%) had an mRS of 4 ( Table 3 ). One patient (1.3%) underwent retreatment (endovascular) because of a residual aneurysm (OKM A). Complications Seven patients (8.9%) had thromboembolic complications during the peri-procedural period; 6 were asymptomatic, and all 7 were managed with a tirofiban bolus. Hemorrhagic complications occurred in 4 cases (5.1%), all intraparenchymal; only 1 caused a symptomatic and persisting deficit (mRS 4). Of these hemorrhagic events, 1 was an intraoperative vessel perforation related to microcatheter navigation, while the other 3 occurred post-procedure. One additional procedural complication was an extracranial dissection (1.3%). There were no deaths in this cohort (0% mortality, Table 3 ). DISCUSSION The use of flow diverter (FD) devices for distal anterior cerebral artery (DACA) aneurysms has expanded significantly over the past decade, spurred by technological refinements that extend FD applicability beyond the ICA. This multicenter study of 79 unruptured DACA aneurysms demonstrated high technical success, promising long-term occlusion rates, and a relatively low frequency of adverse events. Comparison with other studies of newer, low-profile FDs underscores the potential advantages of FD treatment in challenging distal vessel locations, reinforcing the emerging consensus on the device’s safety and efficacy. Navigability and deliverability are key performance indicators for FDs in small, tortuous vessels. Our cohort achieved a 97.5% success rate with a single device, aligning with technical success rates of 98–100% reported in studies involving low-profile FDs for small-caliber arteries [ 11 , 12 , 13 ]. Factors that contributed to this success likely include improved stent design, thinner struts, and greater radiopacity. Notably, 81% of our procedures used a femoral approach, while 19% were radial, reflecting the versatility of the device. Previous multicenter studies of the Silk Vista Baby (SVB) have shown similar results. Martínez-Galdámez et al. reported a 100% technical success in 41 patients [ 10 ], while Rodríguez-Fernández et al. described a 100% success rate in 50 treated aneurysms [ 14 ]. In more recent work, Vasconcellos-de-Oliveira-Souza et al. described a series of 57 aneurysms beyond the circle of Willis, with a 100% deployment success rate and no hemorrhagic complications (15). Thromboembolic events were the most common procedural complication in our cohort (8.9%), although the majority were clinically silent and resolved without lasting deficits. Similar rates have been reported by Rodríguez-Fernández et al. (7.6%)[ 14 ] and Bhogal et al. (~ 6.8% in a UK cohort)[ 10 ]. Early administration of glycoprotein IIb/IIIa inhibitors (e.g., tirofiban) was beneficial in preventing or minimizing permanent ischemic damage. Our study documented hemorrhages in 4 patients (5.1%), only 1 of which led to permanent morbidity (mRS 4). The overall absence of mortality (0%) parallels other experiences with the SVB device [ 11 , 14 , 15 ]. Interestingly, in a series by Vasconcellos-de-Oliveira-Souza et al. that included 40.4% ruptured aneurysms, no hemorrhagic complications were recorded, indicating that well-chosen patients and meticulous periprocedural management can potentially mitigate bleeding risks [ 15 ]. A hallmark of FD treatment is the progressive occlusion of aneurysms. Immediate post-deployment imaging often reveals minimal change, with significant aneurysm thrombosis occurring over subsequent weeks to months. In our series, the final adequate occlusion (OKM C + D) rate was 76% at a median 12-month follow-up, and 69.6% achieved complete occlusion (OKM D). These findings are in line with previously documented occlusion rates of 60–70% at 6–9 months, climbing to 80–90% by 12–18 months [ 13 , 17 ]. Most patients (over 90%) were at mRS ≤ 2 by the final follow-up, with no mortality reported, supporting the accumulating evidence that newer-generation FD devices can be safely and effectively utilized in small or distal vessels [ 18 ]. Retreatment occurred in just 1.3% of cases, reflecting durable parent vessel reconstruction that facilitates stable aneurysm occlusion. Retreatment rates under 5% are commonly reported in similar studies using low-profile FDs in distal or anatomically complex regions [ 19 , 20 ]. Limitations The retrospective design, lack of core laboratory imaging analysis, and heterogeneity in follow-up imaging methods represent the main limitations of our study. Although multicenter experiences and meta-analyses generally support the safety and efficacy of low-profile FDs, future prospective, randomized trials comparing these devices with alternative treatments (coiling, stent-assisted coiling, microsurgery, or conservative management) would be beneficial. Variations in local endovascular protocols, antiplatelet regimens, and use of glycoprotein IIb/IIIa inhibitors may also affect complication and occlusion rates. Standardization of protocols would help clarify outcome differences in future collaborative research. Conclusions Our findings indicate that the Silk Vista Baby flow diverter is a safe and effective treatment option for distal anterior cerebral artery (DACA) aneurysms. Neurointerventionalists must be aware of potential complications and be able to manage them, even though they are asymptomatic in most cases. The results contribute to the growing body of evidence supporting the use of low-profile FDs in challenging distal locations. Declarations Funding No funding was received for this research. Competing Interests: LS: unrelated to the current study, Penumbra (paid lectures). FS: Outside the submitted work received lecturer’s fee from Idorsia Pharmaceuticals for the past 36 months. OG: Outside the submitted work, MicroVention proctor for the WEB device, Stryker consultant, Route 92 consultant. ML: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. AMA: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AP: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AEH: Consultant/Speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92, Perfuze, CorTech, Shockwave, Toro and Xcath. Principal Investigator: COMPLETE study – Penumbra, LVO SYNCHRONISE – Viz.ai, MARRS - Perfuze, RESCUE - ICAD - Medtronic. Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. DSMB - COMAND trial. ML Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board) ; all not directly related to the present work. CC consultant for Medtronic, Microvention, Cerenovus, Stryker, Anaconda, unrelated to the current study. Availability of data and material Data are available upon reasonable request to the Principal Investigator. Ethics approval All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study is part of a nonprofit research protocol approved by the ethics committee of the coordinating center (Fondazione Policlinico Universitario A.Gemelli IRCCS, protocol ID 3583). Informed consent Informed consent was waived in consideration of the retrospective nature of this study. 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Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature. AJNR Am J Neuroradiol. 2011;32:1232–1236. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations Competing interest reported. LS: unrelated to the current study, Penumbra (paid lectures). FS: Outside the submitted work received lecturer’s fee from Idorsia Pharmaceuticals for the past 36 months. OG: Outside the submitted work, MicroVention proctor for the WEB device, Stryker consultant, Route 92 consultant. ML: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. AMA: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AP: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AEH: Consultant/Speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92, Perfuze, CorTech, Shockwave, Toro and Xcath. Principal Investigator: COMPLETE study – Penumbra, LVO SYNCHRONISE – Viz.ai, MARRS - Perfuze, RESCUE - ICAD - Medtronic. Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. DSMB - COMAND trial. ML Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board) ; all not directly related to the present work. CC consultant for Medtronic, Microvention, Cerenovus, Stryker, Anaconda, unrelated to the current study. Supplementary Files Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jul, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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LS: unrelated to the current study, Penumbra (paid lectures). FS: Outside the submitted work received lecturer’s fee from Idorsia Pharmaceuticals for the past 36 months. OG: Outside the submitted work, MicroVention proctor for the WEB device, Stryker consultant, Route 92 consultant. ML: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. AMA: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AP: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AEH: Consultant/Speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92, Perfuze, CorTech, Shockwave, Toro and Xcath. Principal Investigator: COMPLETE study – Penumbra, LVO SYNCHRONISE – Viz.ai, MARRS - Perfuze, RESCUE - ICAD - Medtronic. Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. DSMB - COMAND trial. ML Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board) ; all not directly related to the present work. CC consultant for Medtronic, Microvention, Cerenovus, Stryker, Anaconda, unrelated to the current study.","formattedTitle":"Silk Vista baby for the Treatment of Distal Anterior Cerebral Artery Aneurysms","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFlow diverters (FDs) were initially approved for large, complex, unruptured aneurysms located in the internal carotid artery (ICA). Over time, their use has been extended to smaller aneurysms (less than 10 mm) and those involving the ICA terminus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. FDs have demonstrated excellent occlusion rates\u0026mdash;75\u0026ndash;95%\u0026mdash;with higher rates of success for smaller aneurysms and after one year of follow-up [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additional studies have confirmed their safety and efficacy in managing small- and medium-sized aneurysms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], as well as their suitability for ruptured cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConventional coiling of distal anterior cerebral artery aneurysms (DACA) has been reported to carry a higher risk of procedure-related rupture than non-DACA aneurysms, potentially because of the more distal location and consequently less control over coil and microcatheter deployment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As a result, exploring alternative endovascular techniques\u0026mdash;particularly flow diverters\u0026mdash;has gained traction. The off-label use of FDs for distal aneurysms remains somewhat controversial, and data on long-term outcomes for aneurysms situated at bifurcations or beyond the circle of Willis (e.g., DACA or pericallosal artery aneurysms) remain limited [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Silk Vista Baby (SVB) FD (Balt, Montmorency, France) is a nitinol stent designed for small vessels with diameters of 1.5\u0026ndash;3.5 mm. It is delivered via a 0.017-inch microcatheter and incorporates platinum into its nitinol structure, enhancing radiopacity, navigability, and safety [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The purpose of this study was to analyze radiological and clinical outcomes in patients with unruptured aneurysms treated using SVB, based on data from an international multicenter consortium.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Population\u003c/h2\u003e \u003cp\u003eThis analysis included patients with unruptured DACA aneurysms treated with SVB from the CRETA Consortium [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e](Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). They underwent endovascular treatment across multiple academic centers in North and South America, Europe, and Asia. Data were gathered on patient demographics, aneurysm characteristics, procedural details, complications, and clinical/radiographic outcomes. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. This study is part of a nonprofit research protocol approved by the ethics committee of the coordinating center (XXXXX).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes and Complications\u003c/h3\u003e\n\u003cp\u003eThe primary endpoints were aneurysm occlusion at last follow-up and the incidence of both hemorrhagic and thromboembolic complications. Radiological outcomes were measured through digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA), and graded using the O\u0026rsquo;Kelly\u0026ndash;Marotta (OKM) scale. Secondary endpoints included technical success, procedural complications, retreatment rates, imaging-based assessment of covered branches, and functional outcomes at the last follow-up. Functional outcomes were assessed with the modified Rankin Scale (mRS).\u003c/p\u003e \u003cp\u003eThromboembolic complications were recorded from the day of the procedure through the last follow-up. Intra-procedural thromboembolic events were identified by DSA evidence of thrombus formation, delayed vessel filling, or complete vascular occlusion. Post-procedural events were identified based on clinical symptoms or imaging findings (CTA, MRI, or non-contrast CT). Only ischemic strokes in the treated vessel territory were included, and ischemic complications were classified as symptomatic if they resulted in patient-reported symptoms or clinical signs of transient or persistent ischemia. Complications persisting at three months were deemed permanent.\u003c/p\u003e \u003cp\u003eHemorrhagic complications were identified either intraoperatively (via contrast extravasation on DSA) or through post-procedure imaging. Hemorrhages were included if they occurred from the time of the procedure until the last follow-up, and were classified as symptomatic if the patient reported related symptoms or showed neurological signs. Unlike ischemic events, hemorrhagic complications included all vascular territories.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive analysis was performed in STATA 17.0 (StataCorp, Texas, USA). No inferential statistics were conducted. Categorical variables are shown as counts (percentages), and continuous variables as medians (IQR).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eBaseline Patient and Aneurysm Characteristics\u003c/h2\u003e \u003cp\u003eSeventy-nine patients (median age: 61 years, IQR 53\u0026ndash;67) with 79 DACA aneurysms treated with a flow diverter (FD) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were included from 20 centers. The majority (74.7%) were female (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e). On admission, all patients were functionally independent (mRS 0\u0026ndash;2). Twenty-two patients (27.8%) had a previous subarachnoid hemorrhage (SAH), of which 18 (22.8%) were from the same DACA aneurysm. These 18 patients later underwent FD retreatment because of aneurysm recurrence. A total of 22 patients (27.8%) had already undergone an endovascular procedure: 19 had coiling and 3 underwent another form of endovascular intervention.\u003c/p\u003e \u003cp\u003eOf the 79 aneurysms, 71 (89.9%) were saccular and 8 (10.1%) were fusiform (Table\u0026nbsp;2). The median parent vessel diameter was 1.9 mm (IQR 1.7\u0026ndash;2.1). Fifty-two aneurysms (65.8%) had an arterial branch originating from the aneurysm.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Characteristics and Medications\u003c/h2\u003e \u003cp\u003eIn 64 (81%) cases, the procedure was performed via femoral access; the remaining 15 (19%) were done via radial access. General anesthesia was used in all cases. A triaxial system was used in 70 procedures (88.6%) and a biaxial system in 9 (11.4%). A single FD was deployed in 77 cases (97.5%), while 2 stents were required in 2 cases (2.5%). Adjunctive coiling was performed in 4 aneurysms (5%), typically those with an irregular morphology and with at least one dimension (height, width, or depth) of 6.7 mm or larger (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eAll patients received an antiplatelet regimen prior to the procedure. The most common regimen was aspirin plus clopidogrel (70.9%, 56 patients). Aspirin plus ticagrelor (21.5%, 17 patients) or other combinations (e.g., aspirin plus prasugrel, aspirin plus ticlopidine) were used in the remaining patients (7.6%). Platelet function testing was performed in 42 of 79 patients (53.1%), most commonly via light transmission platelet aggregation (39 of 42). Clopidogrel resistance was found in 13 of these 42 patients (31%); in these cases, clopidogrel was replaced with ticagrelor before the endovascular procedure.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical and Imaging Outcomes\u003c/h3\u003e\n\u003cp\u003eImmediately after the procedure, complete angiographic occlusion (OKM D) was achieved in 8 aneurysms (10.1%), while adequate occlusion (OKM C or D) was observed in 14 (17.7%). At the last radiological follow-up, 55 cases (69.6%) had complete occlusion (OKM D), and 60 (76%) achieved adequate occlusion (OKM C or D). The median imaging follow-up period was 12 months (IQR 9.5\u0026ndash;24), with DSA in 46 patients (58.2%), MRA in 18 (22.8%), and CTA in 10 (12.7%). In-stent stenosis was observed in 16 cases (20.3%), attributed entirely to intimal hyperplasia.\u003c/p\u003e \u003cp\u003eThe median clinical follow-up period was 13 months (IQR 6.5\u0026ndash;25); five patients (6.3%) were lost to follow-up. At the last follow-up, the mRS score was 0 in 79.7% of patients, 1 in 7.6%, and 2 in 3.8%; one patient (1.3%) had an mRS of 4 (\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e). One patient (1.3%) underwent retreatment (endovascular) because of a residual aneurysm (OKM A).\u003c/p\u003e\n\u003ch3\u003eComplications\u003c/h3\u003e\n\u003cp\u003eSeven patients (8.9%) had thromboembolic complications during the peri-procedural period; 6 were asymptomatic, and all 7 were managed with a tirofiban bolus. Hemorrhagic complications occurred in 4 cases (5.1%), all intraparenchymal; only 1 caused a symptomatic and persisting deficit (mRS 4). Of these hemorrhagic events, 1 was an intraoperative vessel perforation related to microcatheter navigation, while the other 3 occurred post-procedure. One additional procedural complication was an extracranial dissection (1.3%). There were no deaths in this cohort (0% mortality, \u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe use of flow diverter (FD) devices for distal anterior cerebral artery (DACA) aneurysms has expanded significantly over the past decade, spurred by technological refinements that extend FD applicability beyond the ICA. This multicenter study of 79 unruptured DACA aneurysms demonstrated high technical success, promising long-term occlusion rates, and a relatively low frequency of adverse events. Comparison with other studies of newer, low-profile FDs underscores the potential advantages of FD treatment in challenging distal vessel locations, reinforcing the emerging consensus on the device\u0026rsquo;s safety and efficacy.\u003c/p\u003e \u003cp\u003eNavigability and deliverability are key performance indicators for FDs in small, tortuous vessels. Our cohort achieved a 97.5% success rate with a single device, aligning with technical success rates of 98\u0026ndash;100% reported in studies involving low-profile FDs for small-caliber arteries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Factors that contributed to this success likely include improved stent design, thinner struts, and greater radiopacity. Notably, 81% of our procedures used a femoral approach, while 19% were radial, reflecting the versatility of the device.\u003c/p\u003e \u003cp\u003ePrevious multicenter studies of the Silk Vista Baby (SVB) have shown similar results. Mart\u0026iacute;nez-Gald\u0026aacute;mez et al. reported a 100% technical success in 41 patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], while Rodr\u0026iacute;guez-Fern\u0026aacute;ndez et al. described a 100% success rate in 50 treated aneurysms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In more recent work, Vasconcellos-de-Oliveira-Souza et al. described a series of 57 aneurysms beyond the circle of Willis, with a 100% deployment success rate and no hemorrhagic complications (15).\u003c/p\u003e \u003cp\u003eThromboembolic events were the most common procedural complication in our cohort (8.9%), although the majority were clinically silent and resolved without lasting deficits. Similar rates have been reported by Rodr\u0026iacute;guez-Fern\u0026aacute;ndez et al. (7.6%)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and Bhogal et al. (~\u0026thinsp;6.8% in a UK cohort)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Early administration of glycoprotein IIb/IIIa inhibitors (e.g., tirofiban) was beneficial in preventing or minimizing permanent ischemic damage.\u003c/p\u003e \u003cp\u003eOur study documented hemorrhages in 4 patients (5.1%), only 1 of which led to permanent morbidity (mRS 4). The overall absence of mortality (0%) parallels other experiences with the SVB device [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interestingly, in a series by Vasconcellos-de-Oliveira-Souza et al. that included 40.4% ruptured aneurysms, no hemorrhagic complications were recorded, indicating that well-chosen patients and meticulous periprocedural management can potentially mitigate bleeding risks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA hallmark of FD treatment is the progressive occlusion of aneurysms. Immediate post-deployment imaging often reveals minimal change, with significant aneurysm thrombosis occurring over subsequent weeks to months. In our series, the final adequate occlusion (OKM C\u0026thinsp;+\u0026thinsp;D) rate was 76% at a median 12-month follow-up, and 69.6% achieved complete occlusion (OKM D). These findings are in line with previously documented occlusion rates of 60\u0026ndash;70% at 6\u0026ndash;9 months, climbing to 80\u0026ndash;90% by 12\u0026ndash;18 months [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost patients (over 90%) were at mRS\u0026thinsp;\u0026le;\u0026thinsp;2 by the final follow-up, with no mortality reported, supporting the accumulating evidence that newer-generation FD devices can be safely and effectively utilized in small or distal vessels [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Retreatment occurred in just 1.3% of cases, reflecting durable parent vessel reconstruction that facilitates stable aneurysm occlusion. Retreatment rates under 5% are commonly reported in similar studies using low-profile FDs in distal or anatomically complex regions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe retrospective design, lack of core laboratory imaging analysis, and heterogeneity in follow-up imaging methods represent the main limitations of our study. Although multicenter experiences and meta-analyses generally support the safety and efficacy of low-profile FDs, future prospective, randomized trials comparing these devices with alternative treatments (coiling, stent-assisted coiling, microsurgery, or conservative management) would be beneficial. Variations in local endovascular protocols, antiplatelet regimens, and use of glycoprotein IIb/IIIa inhibitors may also affect complication and occlusion rates. Standardization of protocols would help clarify outcome differences in future collaborative research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings indicate that the Silk Vista Baby flow diverter is a safe and effective treatment option for distal anterior cerebral artery (DACA) aneurysms. Neurointerventionalists must be aware of potential complications and be able to manage them, even though they are asymptomatic in most cases. The results contribute to the growing body of evidence supporting the use of low-profile FDs in challenging distal locations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS: unrelated to the current study, Penumbra (paid lectures). FS: Outside the submitted work received lecturer\u0026rsquo;s fee from Idorsia Pharmaceuticals for the past 36 months. OG: Outside the submitted work, MicroVention proctor for the WEB device, Stryker consultant, Route 92 consultant. ML: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. AMA: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AP: educational grants from Medtronic, Stryker, Balt and Microvention/Terumo unrelated to the current study. AEH: Consultant/Speaker: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care, Galaxy Therapeutics, Route 92, Perfuze, CorTech, Shockwave, Toro and Xcath. Principal Investigator: COMPLETE study \u0026ndash; Penumbra, LVO SYNCHRONISE \u0026ndash; Viz.ai, MARRS - Perfuze, RESCUE - ICAD - Medtronic. Steering Committee/Publication committee member: SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. DSMB - COMAND trial. ML Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Aeaean Advisers, Metis Innovative, Genomadix, AIDoc and Arsenal Medical; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, Synchron and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery; Data safety monitoring board of Arsenal Medical. FC reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board) ; all not directly related to the present work. CC consultant for Medtronic, Microvention, Cerenovus, Stryker, Anaconda, unrelated to the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request to the Principal Investigator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eThis study is part of a nonprofit research protocol approved by the ethics committee of the coordinating center (Fondazione Policlinico Universitario A.Gemelli IRCCS, protocol ID 3583).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was waived in consideration of the retrospective nature of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKallmes DF, Brinjikji W, Cekirge S, et al. Safety and efficacy of the pipeline embolization device for treatment of intracranial aneurysms: a pooled analysis of 3 large studies. J Neurosurg. 2017;127:775\u0026ndash;780.\u003c/li\u003e\n \u003cli\u003eEnriquez-Marulanda A, Penumaka A, Ogilvy CS, et al. Safety and efficacy of the off-label use of pipeline embolization device based on the 2018 food and drug administration-approved indications for intracranial aneurysms: a single-center retrospective cohort study. Neurosurgery. 2022;90:700\u0026ndash;707.\u003c/li\u003e\n \u003cli\u003eHanel RA, Kallmes DF, Lopes DK, et al. Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg. 2020;12:62\u0026ndash;66.\u003c/li\u003e\n \u003cli\u003eShehata MA, Ibrahim MK, Ghozy S, et al. Long-term outcomes of flow diversion for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg. 2023;15:898\u0026ndash;902.\u003c/li\u003e\n \u003cli\u003eDibas M, Vivanco-Suarez J, Lopes DK, Hanel RA, Rodriguez-Calienes A, Cortez GM, Fifi JT, Devarajan A, Toth G, Patterson TE, Altschul D, Pereira VM, Liu XYE, Puri AS, K\u0026uuml;hn AL, Guerrero WR, Khandelwal P, Bach I, Kan PT, Edhayan G, Martinez-Galdamez M, Given C, Gross BA, Narayanan S, Galecio-Castillo M, Derakhshani S, Ortega-Gutierrez S. Treatment of Unruptured Small and Medium-Sized Wide Necked Aneurysms Using the 64-Wire Surpass Evolve: A Subanalysis From the SEASE International Registry. J Am Heart Assoc. 2024;13:e036365.\u003c/li\u003e\n \u003cli\u003eTen Brinck MFM, J\u0026auml;ger M, de Vries J, Grotenhuis JA, Aquarius R, M\u0026oslash;rkve SH, Rautio R, Numminen J, Raj R, Wakhloo AK, Puri AS, Taschner CA, Boogaarts HD. Flow diversion treatment for acutely ruptured aneurysms. J Neurointerv Surg. 2020;12:283\u0026ndash;288.\u003c/li\u003e\n \u003cli\u003eNguyen TN, Raymond J, Roy D, Chagnon M, Weill A, Iancu-Gontard D, Guilbert F. Endovascular treatment of pericallosal aneurysms. J Neurosurg. 2007;107:973\u0026ndash;976.\u003c/li\u003e\n \u003cli\u003eScarcia L, Claren\u0026ccedil;on F, Dmytriw AA, Shotar E, Premat K, Jabbour P, Tjoumakaris SI, Gooch R, Psychogios MN, Ntoulias N, Sporns PB, Puri AS, Singh J, Kuhn AL, Hassan AE, Algin O, M\u0026ouml;hlenbruch MA, Hohenstatt S, Russo R, Bergui M, Goren O, Kole MJ, Bankole NDA, Bibi R, Boulouis G, Morimoto T, Sakakibara F, Pop R, Juravle C, Ho JW, Ferrario A, Pujol Lereis V, Cooper J, Gandhi CD, Salsano G, Castellan L, Camilli A, Consoli A, Sgreccia A, Raz E, Chung C, Burel J, Papagiannaki C, Rasheed U, Baqir Hassan KM, Hong T, Ji Z, Rautio R, Sinislao M, Ruggiero M, Lafe E, Da Ros V, Bellini L, Gabrieli JD, Cester G, Levitt MR, Carroll KT, Abecassis ZA, Caragliano AA, Vinci SL, Bellanger G, Cognard C, Marnat G, Saleille L, Limbucci N, Capasso F, Piano M, Rollo C, Guedon A, Arpaia F, Romi A, Di Caterino F, Biondi A, Kalsoum E, Mykola V, Guenego A, Patel AB, Pereira VM, Pedicelli A, Alexandre AM; CRETA investigators. Flow-diverting stents for the treatment of unruptured distal anterior cerebral artery aneurysms: analysis of the CRETA Registry. J Neurointerv Surg. 2025; [Epub ahead of print].\u003c/li\u003e\n \u003cli\u003eCagnazzo F, Fanti A, Lefevre PH, Derraz I, Dargazanli C, Gascou G, Riquelme C, Ahmed R, Bonafe A, Costalat V. Distal anterior cerebral artery aneurysms treated with flow diversion: experience of a large-volume center and systematic review of the literature. J Neurointerv Surg. 2021;13:42\u0026ndash;48.\u003c/li\u003e\n \u003cli\u003eMart\u0026iacute;nez-Gald\u0026aacute;mez M, Biondi A, Kalousek V, Pereira VM, Ianucci G, Gentric JC, Mosimann PJ, Brisbois D, Schob S, Qu\u0026auml;schling U, Kaesmacher J, Ognard J, Escart\u0026iacute;n J, Tsang COA, Čulo B, Chabert E, Turjman F, Barbier C, Mihalea C, Spelle L, Chapot R. Periprocedural safety and technical outcomes of the new Silk Vista Baby flow diverter for the treatment of intracranial aneurysms: results from a multicenter experience. J Neurointerv Surg. 2019;11:723\u0026ndash;727.\u003c/li\u003e\n \u003cli\u003eBhogal P, Makalanda H, Wong K, et al. The Silk Vista Baby\u0026mdash;the UK experience. Interv Neuroradiol. 2022;28:201\u0026ndash;212.\u003c/li\u003e\n \u003cli\u003eGavrilovic V, Dapoto A, Marotti N, et al. Silk vista baby is a safe and technically feasible flow diverting stent for distal aneurysm treatment. Front Neurol. 2021;12:676749.\u003c/li\u003e\n \u003cli\u003eHanel RA, Cortez GM, Benalia VHC, et al. Patient outcomes after treatment of brain aneurysm in small diameter vessels with the silk vista baby flow diverter: a systematic review. Interv Neuroradiol. 2024;30:5\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eRodr\u0026iacute;guez-Fern\u0026aacute;ndez C, Ruiz-Garcia P, Garcia-Sanchez MJ, et al. Technical success, procedural safety, and efficacy of the Silk Vista Baby in the treatment of cerebral aneurysms over a mid-to-long-term follow-up.\u0026nbsp;Front Neurol. 2024;15:1369443.\u003c/li\u003e\n \u003cli\u003eVasconcellos-de-Oliveira-Souza N, Benalia VH, Ortega Moreno DA, et al. Silk vista baby flow diversion beyond the circle of Willis: a single-center experience with long-term outcomes. Interv Neuroradiol. 2024;30:846\u0026ndash;853.\u003c/li\u003e\n \u003cli\u003eYan Y, Zhu D, Tang H, et al. Safety and efficacy of flow diverter treatment for aneurysm in small cerebral vessels: a systematic review and meta-analysis. World Neurosurg. 2018;115:54\u0026ndash;64.\u003c/li\u003e\n \u003cli\u003eSch\u0026uuml;ngel MS, Qu\u0026auml;schling U, Weber E, et al. Endovascular treatment of intracranial aneurysms in small peripheral vessel segments\u0026mdash;efficacy and intermediate follow-up results of flow diversion with the silk vista baby low-profile flow diverter. Front Neurol. 2021;12:671915.\u003c/li\u003e\n \u003cli\u003eElek A, Karagoz S, Dindar GN, Yucel S, Cinar C, Kusbeci M, Ozturk E, Oran I. Safety and efficacy of low profile flow diverter stents for intracranial aneurysms in small parent vessels: systematic review and meta-analysis. J Neurointerv Surg. 2025; [Epub ahead of print].\u003c/li\u003e\n \u003cli\u003eBhogal P, Bleise C, Chudyk J, Lylyk I, Viso R, Perez N, Henkes H, Lylyk P. The p48MW Flow Diverter-Initial Human Experience. Clin Neuroradiol. 2021;31:135\u0026ndash;145.\u003c/li\u003e\n \u003cli\u003eBodily KD, Cloft HJ, Lanzino G, Kallmes DF. Stent-assisted coiling in acutely ruptured intracranial aneurysms: a qualitative, systematic review of the literature. AJNR Am J Neuroradiol. 2011;32:1232\u0026ndash;1236.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6613699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6613699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003cbr\u003e\nTreating small-caliber vessel aneurysms with flow diverters presents challenges due to narrow luminal diameters and tortuous vasculature, which make navigation and deployment of conventional devices using standard microcatheters more difficult. The Silk Vista Baby (SVB, Balt, Montmorency, France) flow diverter was developed to treat intracranial aneurysms located in smaller vessels or more distal lesions and is compatible with 0.017″ microcatheters. We present the largest multicenter analysis to date evaluating the outcomes of SVB use in unruptured distal anterior cerebral artery (DACA) aneurysms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nRetrospective data from 20 centers were reviewed for patients with unruptured DACA aneurysms treated with SVB. The following were recorded: demographic information, clinical presentation, radiographic characteristics, procedural complications, and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nSeventy-nine patients (79 DACA aneurysms) were treated between January 2018 and December 2022; 59 were female (74.7%), and the median age was 61 years (IQR 53–67). Most aneurysms were saccular (91.7%), and 61.9% involved a branch. The median parent vessel diameter was 1.9 mm (IQR 1.7–2.1). A single stent was implanted in 97.5% of cases; 2.5% required two stents. The median imaging follow-up was 12 months (IQR 9.5–24). At the last follow-up, 76% of aneurysms showed complete or near-complete occlusion (O’Kelly–Marotta scale C or D). Overall, thromboembolic or hemorrhagic complications occurred in 14% of patients, with only 2 cases being symptomatic; mortality rate was 0%. The retreatment rate was 1.3%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nIn this multicenter series, the SVB flow diverter emerged as a safe and effective treatment option for unruptured DACA aneurysms.\u003c/p\u003e","manuscriptTitle":"Silk Vista baby for the Treatment of Distal Anterior Cerebral Artery Aneurysms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-14 12:06:44","doi":"10.21203/rs.3.rs-6613699/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b32ffff-41f0-4cd6-ac75-8e669b964b0e","owner":[],"postedDate":"May 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:01:46+00:00","versionOfRecord":{"articleIdentity":"rs-6613699","link":"https://doi.org/10.1007/s00234-025-03678-y","journal":{"identity":"neuroradiology","isVorOnly":false,"title":"Neuroradiology"},"publishedOn":"2025-07-02 15:57:27","publishedOnDateReadable":"July 2nd, 2025"},"versionCreatedAt":"2025-05-14 12:06:44","video":"","vorDoi":"10.1007/s00234-025-03678-y","vorDoiUrl":"https://doi.org/10.1007/s00234-025-03678-y","workflowStages":[]},"version":"v1","identity":"rs-6613699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6613699","identity":"rs-6613699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}