Flow diverting stents for anterior communicating artery aneurysms: A systematic review and meta-analysis of safety, efficacy, and anatomic determinants.

Background: Flow diversion for anterior communicating artery (ACom) aneurysms remains technically challenging due to small vessel caliber, bifurcation anatomy, and perforator involvement. Although case series suggest feasibility, the overall efficacy and safety of flow-diverter (FD) treatment for ACom aneurysms are not well established. Purpose: To synthesize the available evidence on occlusion rates, complications, clinical outcomes, and retreatment following FD treatment for ACom aneurysms. Materials and methods: Following PRISMA guidelines, databases (PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library) were searched for studies published January 2010–September 2025 including ≥ 3 patients treated with FD devices reporting angiographic or clinical outcomes. Extracted data encompassed study characteristics, demographics, aneurysm morphology, treatment details, occlusion, complications, and modified Rankin Scale (mRS). Pooled proportions with 95% confidence intervals (CIs) were calculated via random-effects model in R. Results: Twelve studies (297 patients; 304 ACom aneurysms) were included. Mean age was 64.6 ± 8.4 years; 50.4% were female. Aneurysms were mostly saccular (90.7%), unruptured (76.8%), and small (< 10 mm; mean 4.5 mm). PED was used in 43% of cases; adjunctive coiling in 17.6%. Pooled complete/near-complete occlusion (> 90%) was 78% (95% CI: 66%–86%) at mean 12.5-month follow-up. Pooled complication rate was 21% (95% CI: 13%–31%) and mortality 1% (95% CI: 0%–3%), with permanent morbidity ranged from 5 to 7% across reporting studies. Retreatment was 3.7%; good outcomes (mRS 0–2) 94.7%. Conclusion: FD may offer a technically feasible and potentially effective treatment option for select ACom aneurysms, with pooled data demonstrating 78% near-complete or complete occlusion and 94.7% good functional outcomes at 12.5 month follow-up. However, its role remains investigational, warranting prospective studies to better define long-term safety, durability, and optimal patient selection.