Flow Diverter Assisted Embolization of Ruptured Aneurysms is Associated with Increased Hemorrhagic Complications: Prognostic Factors and Outcomes in Neuroendovascular Treatment of Subarachnoid Hemorrhages

BACKGROUND: Neuroendovascular interventions, including pipeline embolization device (PED)/flow diverter placement and coil embolization, are increasingly used in the management of nontraumatic subarachnoid hemorrhages (SAH). However, literature on trends, predictors of patient selection, and complications remains limited. This study aims to identify factors influencing treatment selection and risks associated with PED versus coil embolization in SAH. METHODS: The 2016 to 2021 National Inpatient Sample was used to identify adult inpatients with a primary diagnosis of nontraumatic SAH. Univariate and multivariable analyses adjusting for demographics, comorbidity status, and hemorrhage etiology were used to characterize statistical associations. RESULTS: Of 62,567 patients identified as having an SAH from 2016 to 2021, 409 patients (0.65%) underwent PED, and 6834 patients (10.9%) underwent coil embolization. The remaining 88% underwent nonendovascular management. Complications associated with PED placement and not coil embolization included gastrointestinal (5.1% vs. 2.2%; P < 0.05) and respiratory tract bleeding (3.2% vs. 0.7%; P < 0.001). Those who underwent PED were less likely to have hydrocephalus (47.4% vs. 56.5%; P < 0.05) and receive external ventricular drain or ventriculoperitoneal shunt placement (38.9% vs. 48.4%; P < 0.01). After controlling for confounding factors, predictors for receiving coil embolization instead of PED placement included SAH originating from the anterior communicating artery (odds ratio [OR]: 4.0; 95% confidence interval [CI]: 2.87-5.90; P < 0.001), posterior communicating artery (OR: 2.0; CI: 1.90-3.63; P < 0.001), and middle cerebral artery (OR: 2.02; CI: 1.36-3.13; P < 0.05). CONCLUSIONS: PED is associated with a higher incidence of systemic hemorrhagic complications, particularly gastrointestinal and respiratory tract bleeding, compared to coil embolization. Patients undergoing PED require careful patient selection and postprocedural management.