The SAFEST Study: Survey on Antiplatelets in Flow Diversion for Aneurysm Endovascular Treatment.

Background: Flow diversion has emerged as a promising treatment strategy for intracranial aneurysms, yet the influence of antiplatelet therapy on treatment outcomes remains uncertain. Regional and institutional variability in antiplatelet regimens further complicates treatment standardization. This survey aimed to investigate common practices of antiplatelet medication usage in flow diversion for intracranial aneurysms worldwide. Methods: An anonymous online survey explored antiplatelet therapy regimens in flow diverter implantations, including agent selection, dosing, and duration. The survey was distributed through international neurointerventional societies and mailing lists. Results: Participants included 442 from 53 countries, revealing that most practitioners agree on using dual antiplatelet therapy, with 67% combining low-dose aspirin with clopidogrel. However, alternative P2Y12 inhibitors are increasingly being used with the main reasons for preferring ticagrelor (21%) over prasugrel (10%) being its availability and bleeding risk, whereas the main reason for using prasugrel over ticagrelor is patient compliance. Resistance testing for antiplatelet agents was conducted by 62% of survey respondents, with the VerifyNow system being the most common method. Strategies to manage resistance included dose escalation (17%) and switching (83%) to alternative agents. Interest in participating in future trials investigating antiplatelet therapy duration and dual antiplatelet therapy versus single antiplatelet therapy was high (77% and 58%, respectively). Conclusion: Antiplatelet treatment strategies following flow diversion procedures vary globally, with a growing interest in alternative agents and a willingness to participate in future trials. Standardization efforts and further investigation are warranted for optimizing neurointerventional outcomes.