National Trends in the Use of Flow Diversion for Management of Intracranial Aneurysms

Flow diversion (FD) has become increasingly common over the past decade. Although predominantly used for unruptured aneurysms given the need for patients to take dual antiplatelet therapy, these devices have been increasingly leveraged for ruptured aneurysms. FD use remains selective, however, and aneurysm characteristics are unlikely to be the sole driver of FD utilization. This study characterizes recent trends in FD use, with emphasis on patient and hospital factors associated with increased rates of utilization.

This is a retrospective cohort study in which patients who underwent endovascular treatment of an aneurysm from 2020 to 2022 were selected from the National Inpatient Sample and characterized as unruptured or ruptured. Patients with other vascular malformations or traumatic hemorrhages were excluded. The Cochran-Armitage trend test was used to assess trends over time. Multivariable analysis was used to determine variables independently associated with FD use.

In total, 9081 patients met inclusion criteria (5459 unruptured, 3622 ruptured). In the unruptured cohort, 2824 (51.7%) underwent FD. In the ruptured cohort, 500 (13.8%) underwent FD. In the unruptured cohort, FD use trended toward, but did not reach, a significant increase over the study period ( P = .07). However, the ruptured cohort did show a significant increase in FD use over time ( P = .01). The Pacific census division was significantly less likely to use FD in both the unruptured (odds ratio 0.931, P = .002) and ruptured (odds ratio 0.932, P = .020) cohorts. Older age was associated with decreased FD use only in the unruptured group ( P < .0001).

As FD becomes an increasingly common way to treat aneurysms, it is important to assess practice trends and identify potential disparities in using these devices. FD use appears to be increasing for ruptured aneurysms. Determining whether lower FD use in the Pacific division is due to varying practice patterns across the country requires further investigation.