This study demonstrates that the use of SVB FDs for the treatment of small parent artery aneurysms is associated with high technical success and favorable mid-term clinical outcomes. SVB placement was technically successful in 100% of cases, with an overall aneurysm occlusion rate of 93.3% at last follow-up. The incidence of ischemic complications was 10.93%, while SVB-related complications were observed in only 4.69% of patients.

One of the most critical advantages of the SVB is its compatibility with a 0.017‑inch microcatheter, which facilitates access to challenging vascular territories such as distal cerebral arteries. The low crossing profile of SVB not only enables access to small and distal vessels but also contributes to procedural safety by minimizing vascular manipulation, facilitating smoother navigation, and reducing the risk of vasospasm. The device’s 48‑wire braided structure enhances flexibility while providing high radiopacity, thereby making the deployment process safer. Several studies have underscored these characteristics, reporting high technical success rates with minimal complications [15, 16, 18, 19]. Moreover, the SVB’s ability to navigate tortuous vascular anatomy renders it particularly suitable for cases in which larger-caliber conventional flow diverters are not viable.

In terms of efficacy, previous studies have reported occlusion rates ranging from 57.1 to 94% at follow-up periods of up to 12 months [10–12, 14]. Our findings align with this trend, as we observed a final occlusion rate of 93%. Notably, adjunctive materials were utilized in 22 cases (16 cases with coiling and 6 cases with an additional stent), which likely contributed to the high occlusion rates. It is important to note that all four cases of partial occlusion were treated solely with the SVB, without adjunctive materials. Although previous studies have reported the use of adjunctive materials in complex cases, they have not provided detailed subgroup analyses; our study helps to fill this gap.

The use of the SVB in ruptured aneurysms remains a topic of debate. While some studies suggest favorable outcomes, early rebleeding and thrombotic complications continue to be a concern. Although flow diverters inherently have a higher metal coverage compared to conventional stents and are therefore theoretically associated with an increased risk of thrombotic complications, the antiplatelet management strategies are similar in the acute rupture setting regardless of the stent type. Importantly, the use of newer-generation ADP receptor blockers such as prasugrel or ticagrelor, bridging therapy with intravenous antiplatelet agents like tirofiban during on-table loading when necessary, and peri-procedural monitoring with platelet aggregometry can effectively mitigate thrombotic risks. Adjusting therapy based on aggregometry findings during the early perioperative period allows close monitoring and timely intervention to prevent thrombotic events. These strategies have been shown to reduce thrombotic complication rates to acceptable levels even after flow diverter placement for ruptured blister aneurysms, as previously demonstrated in the literature [5].

Russo et al. [20] reported that the SVB shows promise for the treatment of ruptured intracranial aneurysms, although worse clinical outcomes were observed in posterior circulation cases. In their series of 25 patients with ruptured aneurysms, 79.1% achieved a favorable outcome (mRS 0–2), with a mortality rate of 12.5% and complete occlusion achieved in 85.7% at a 3‑month follow-up. In our study, 40.6% of cases presented with SAH, and subgroup analysis further revealed that although complication rates did not significantly differ between the SAH and No-SAH groups, neurological outcomes were worser in SAH patients. Similarly, in the study by Maybaum et al. [16] of 31 SAH patients, 18 achieved complete recovery (GOS 5), 4 had moderate disability (GOS 4), 2 had severe disability (GOS 3), 1 was in an unresponsive wakefulness syndrome (GOS 2), and 6 died (GOS 1).

Another key factor influencing outcomes is the presence of multiple aneurysms. Distal aneurysms are generally not found in isolation; they more frequently coexist with additional aneurysms, which often necessitate the use of additional stents or adjunctive materials. This situation makes it challenging to isolate the outcomes specifically attributable to the SVB. Our subgroup analyses addressed this issue by demonstrating that among patients with isolated distal aneurysms, the overall complication rate was significantly lower, with only one patient experiencing a complication. Although previous studies have not conducted detailed subgroup analyses to highlight this factor, our findings suggest that it can have a direct impact on outcomes.

In patients with multiple aneurysms, one-stage treatment was selectively employed based on individualized risk assessment, anatomical characteristics, and clinical factors. Literature supports that one-stage intervention can prevent rebleeding from untreated aneurysms, alleviate patient anxiety, and reduce the risks and costs associated with multiple procedures [3, 13, 24]. Although staged treatment may offer a lower risk of immediate procedural complications, in cases where the ruptured aneurysm could not be reliably identified, or multiple aneurysms were considered high-risk, one-stage treatment was regarded as both appropriate and safe. Our approach is consistent with these findings, further highlighting the importance of patient-specific treatment planning.

Another important consideration is that, in patients treated with FDs, there is a worldwide trend to use adjunctive materials to fill the aneurysm sac as the aneurysm diameter increases. This strategy is aimed at reducing recurrence by promoting complete occlusion of the aneurysm. In our patient population, we observed a similar pattern, with larger aneurysms more frequently receiving adjunctive coiling or additional stenting to achieve optimal long-term outcomes.

Although the radiological follow-up of jailed branch arteries was not a specific objective of this study, it is known that many crossed side branches become asymptomatically occluded over time, particularly when distal collateral flow is adequate. In our cohort, a side branch was crossed in 17 patients, yet only one of these cases (5.88%) resulted in a clinically evident thrombotic complication.

Although the SVB is a leading low-profile FD for treating distal aneurysms, our study did not include or compare other low-profile FDs such as Fred Jr. or p48 MW. A recent meta-analysis by Elek et al. [10] have compared low-profile FDs for distal aneurysms. Overall, the indicated that ruptured aneurysms had higher complication rates (20%) than unruptured ones (12.7%). In the case of SVB, the complication rate was 15%, with 17.4% in the SAH group and 12.2% in the incidental group. In our study, the overall complication rate was 10.93%, and 11.54% in the SAH group, both of which are slightly better than those reported in the meta-analysis.

Our study’s primary limitations include its retrospective design and relatively small sample size, which may affect the generalizability of our findings. Although our results are promising, particularly in complex aneurysm cases, longer-term follow-up is required to fully assess the durability of SVB treatment. Future prospective multicenter studies with standardized antiplatelet management and imaging follow-up protocols are essential to better define the role of SVB in the treatment of intracranial aneurysms.