Flow Diverters vs. Surgical Clipping in the Treatment of Intracranial Aneurysms: A Contemporary Analysis of Efficacy, Safety, and Patient Selection in the age of Endovascular Innovation
Esther Amarachi Ojukwu*, Victoria Ezinne Ojukwu and Masifon Ekabua
ABSTRACT
Background: Intracranial aneurysms have a high risk of leading to subarachnoid hemorrhage, with resultant high morbidity and mortality. The optimal treatment has traditionally been the invasive surgical clipping, which guarantees long-term aneurysm occlusion. In recent years, we have seen endovascular treatment, particularly flow diverters (FDs), revolutionize the treatment of complex aneurysms by facilitating minimally invasive therapy, especially for difficult cerebrovascular surgeries.
Aim: This review aims to compare the efficacy, safety, and clinical issues of recent flow diverters with surgical clipping in the management of intracranial aneurysms, covering patient selection criteria and procedural outcomes.
Methods: A narrative review was conducted using peer-reviewed research papers from 2010 to 2025 obtained from databases such as PubMed, Scopus, and ScienceDirect. Keywords were “flow diverters,” “surgical clipping,” “intracranial aneurysms,” “Pipeline Embolization Device (PED),” and “endovascular treatment.” Articles were assessed for occlusion rates, complications, retreatment rates, and anaesthetic/perioperative traits.
Results: Surgical clipping continues to have better complete occlusion rates (>90%) and long-term stability with minimal retreatment. Second-generation flow diverters, such as the PED Vantage and Surpass Evolve, now achieve similar occlusion efficacy (up to 94%) with a less invasive procedure, particularly for wide-necked or fusiform aneurysms. FDs are not risk-free, however, with risks including in-stent thrombosis, delayed rupture, and dual antiplatelet therapy dependency. Cost-benefit is strongly system-dependent, and device selection remains overwhelmingly case-dependent.
Conclusion: Both flow diverters and surgical clipping have distinct, context-specific benefits. The optimal strategy must be adapted based on aneurysm morphology, patient comorbidities, and institutional skill sets.
