Efficacy and Safety of Stent-Assisted Coiling Versus Coiling Alone for Ruptured Multilobed Aneurysms: A Multicenter Study

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BACKGROUND: Ruptured multilobed intracranial aneurysms present significant procedural challenges and high recurrence risks in endovascular treatment due to complex geometry and turbulent hemodynamics. Currently, the safety and long-term efficacy of stent-assisted coiling (SAC) versus coiling alone in treating this high-risk morphological subgroup remain clinically controversial; high-quality, large-scale evidence is required. METHODS: Based on a multicenter, prospective registry study (the SANE trial [Subarachnoid Aneurysm Endovascular Cohort Study in China]), 627 consecutive patients with ruptured multilobed intracranial aneurysm treated with SAC or coiling alone were included. Baseline demographics, perioperative safety outcomes (including intraprocedural thrombosis, ischemic stroke, cerebral vasospasm, and rerupture), clinical functional outcomes (modified Rankin Scale score and mortality), and angiographic morphological outcomes (Raymond-Roy Occlusion Classification) were systematically collected. Overlap weighting (average treatment effect in the overlap population) and doubly robust logistic regression models were applied to evaluate the independent clinical effects of different modalities after strict adjustment for confounders, including anatomic morphology and perioperative parameters. RESULTS: The cohort comprised 173 patients treated with coiling alone and 454 treated with SAC. The primary average treatment effect in the overlap population analysis included 610 patients and yielded a pooled Kish effective sample size of 438.74. Before weighting, perioperative ischemic stroke and intraprocedural thrombosis were more frequent with SAC. After weighting, all 16 prespecified covariates had absolute standardized mean differences <0.10. At follow-up, Raymond-Roy Occlusion Classification class I occlusion was observed in 75.8% of the SAC group and 53.9% of the coiling-alone group ( P <0.001). Doubly robust models detected no statistically significant associations between SAC and the evaluated safety outcomes, poor functional outcome at discharge or follow-up, or all-cause mortality (all P ≥0.071). SAC was associated with lower odds of follow-up Raymond-Roy Occlusion Classification class II versus I (odds ratio, 0.401 [95% CI, 0.203–0.795]; P =0.012) and class III versus I (odds ratio, 0.583 [95% CI, 0.307–0.806]; P =0.014). CONCLUSIONS: In this observational ruptured multilobed intracranial aneurysm cohort, SAC was associated with more favorable follow-up angiographic occlusion than coiling alone, without detected differences in perioperative safety or clinical outcomes. These findings do not establish functional superiority and remain subject to residual confounding. REGISTRATION: URL: https://www.chictr.org.cn/ ; Unique identifier: ChiCTR2000032657.

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