We conducted a systematic review and meta-analysis to evaluate the angiographic and periprocedural outcomes for embolization with Flow diverters (FDs) with surface modification (SM).

A literature search was performed across PubMed, Embase, and Cochrane databases from inception to July 2025 to identify studies comparing SM-FDs and non-SM-FDs. Outcomes of interest included periprocedural thromboembolic and hemorrhagic complications, as well as adequate and complete aneurysm occlusion rates at follow-up intervals. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model.

Nine studies, comprising 2,332 patients (SM-FDs:783, non-SM-FDs:1,549), were included. Risks of periprocedural thromboembolic or ischemic complications were lower in the SM-FD group (RR:0.44; CI:0.22-0.87; p=0.019). However, no significant difference was observed for periprocedural hemorrhagic complications (RR:0.74; CI:0.26-2.16; p=0.587). There were no statistically significant differences observed at any follow-up interval (immediate, at 6, and 12 months) in the unadjusted primary analyses of adequate and complete aneurysm occlusion. However, SM-FDs were found to have significantly higher rates of adequate (RR: 1.31; CI: 1.08-1.59; p = 0.006) and complete (RR: 1.20; CI: 1.05-1.36; p = 0.006) occlusion at 6-month follow-up in sensitivity analyses to limit heterogeneity.

Our findings in this large meta-analysis of studies making head-to-head comparisons support the efficacy of SM-FDs in reducing thromboembolic complications. Further prospective studies with more granular design are warranted to confirm these findings.