Comparative analysis of Neuroform Atlas and Enterprise 2 stents in stent-assisted coiling for anterior circulation aneurysms: a propensity score-matched study

Introduction

Stent-assisted coiling (SAC) is a well-established endovascular treatment approach for wide-neck intracranial aneurysms that has expanded the indications for endovascular therapy (1,2). The Neuroform stent system, specifically tailored for neurovascular applications, was first approved in 2002 by the USA Food and Drug Administration. It utilizes an open-cell design and has undergone several generational improvements. In 2007, the Enterprise stent was approved as the main alternative to the Neuroform stent system for the treatment of wide-necked intracranial aneurysms (3).

The Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA, USA) is a new generation of the Neuroform stent approved for SAC (4). It features a self-expanding hybrid cell design and can be delivered through a 0.0165-inch inner diameter microcatheter. This stent offers enhanced stent conformability and coil support, an easy-to-use delivery system, and high deployment accuracy (5).

The Enterprise stent (Codman Neurovascular, Miami Lakes, FL, USA) is a self-expandable laser device and the first to use a closed-cell design. Advantages of this design include the ability of the stent to be partially deployed, recaptured, and redeployed and improvement in keeping coils within the aneurysm (6). Recently, the second-generation Enterprise 2 Vascular Reconstruction Device (EP2) has introduced an optimized geometric design to enhance stent-vessel wall apposition, aiming to reduce operative complications (7).

In the past five years, both Neuroform Atlas and EP2 stents have been extensively utilized for wide-neck aneurysms, with various studies demonstrating their safety and effectiveness (5,8,9). However, limited data exist on the direct comparative benefits of the two stents for SAC, particularly in treating wide-neck aneurysms at the internal carotid artery, where they are commonly used. Consequently, the current study utilizes propensity score matching (PSM) to analyze and compare the feasibility, hospital costs, procedure-related complication rates, and occlusion rates of Neuroform Atlas and EP2 stent deployments. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-595/rc).

Methods

Patient selection

The study protocol was approved by the Institutional Review Board of Beijing Tiantan Hospital (No. QX2019-009-10) and all participants gave informed consent before taking part. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The EP2 and Neuroform Atlas stents have been available at our center since November 2018 and August 2020, respectively. To control the increased risks associated with an early iteration of new technology, patients with intracranial aneurysms who received EP2 SAC treatment between November 2018 and November 2019 and those who received Neuroform Atlas SAC treatment between August 2020 and August 2021 at a single institution were retrospectively enrolled. Inclusion criteria: (I) patients aged 18–80 years and (II) those diagnosed with a wide-necked saccular intracranial aneurysm (neck ≥4 mm or dome-to-neck ratio <2) located in the anterior circulation, treated with either EP2 or Neuroform Atlas SAC. Exclusion criteria: (I) ruptured, fusiform, or dissecting aneurysms; (II) presence of multiple intracranial aneurysms; (III) aneurysms associated with other cerebrovascular diseases such as arteriovenous malformations or fistulas; (IV) pregnancy or lactation; (V) liver, kidney, cardiovascular disease, or malignancy; and (VI) missing follow-up data.

Procedural details

Patients scheduled for endovascular treatment received dual antiplatelet therapy (75 mg clopidogrel and 100 mg aspirin daily) for at least 5 days before the procedure. Platelet function tests were not routinely performed. All procedures were conducted under general anesthesia. Following anesthesia induction, an initial dose of 3,000 IU intravenous heparin was administered, followed by an additional 1,000 IU every hour. The target aneurysm was accessed via a standard transfemoral arterial approach. The EP2 stent was delivered through a Prowler Select Plus microcatheter (Codman Neurovascular, Miami Lakes, FL, USA), while the Neuroform Atlas stent was deployed through SL-10 microcatheters (Stryker Neurovascular, Fremont, USA). Coils were densely packed into the aneurysm sac using the microcatheter jailing technique. In cases where a single stent was insufficient to prevent coil herniation, an overlapping stent technique was applied. Clopidogrel (75 mg/day) was discontinued after 3–6 months post-procedure, while aspirin (100 mg/day) was continued for one year, provided that the aneurysm was completely occluded and the patient remained free of complications. Stent selection was determined by the operator.

Hospitalization and follow-up data

Demographic data (age, sex, smoking, alcohol consumption, and comorbidities), aneurysm characteristics (maximum diameter, neck size, location, parent vessel diameter, dome-to-neck ratio, and bifurcation or side-wall type), procedural details (types of devices, number of devices, stent size, deployment success, and procedure time), in-hospital costs for the stent procedure, and angiographic and clinical outcomes during hospitalization and follow-up were recorded. Clinical and angiographic follow-up visits were scheduled for 3, 6, and 12 months after treatment. Patients with completely occluded aneurysms, as confirmed by digital subtraction angiography (DSA), were monitored annually with magnetic resonance (MR) or computed tomography (CT) angiography.

Angiographic outcomes were classified using the Raymond-Roy occlusion scale: Raymond Class I (complete obliteration), Raymond Class II (residual neck), and Raymond Class III (residual aneurysm) (10). Postoperative CT or MR imaging (MRI) was conducted if patients exhibited symptoms such as hemiparesis, headache, blurred vision, or other neurological symptoms. Perioperative ischemic complications included stent thrombosis (thrombosis within the stent confirmed by DSA), ischemic stroke (an episode of neurological dysfunction caused by focal cerebral ischemia), and transient ischemic attack (TIA) (a transient episode of neurological dysfunction due to focal ischemia of the brain, spinal cord, or retina without acute infarction) within the first postoperative month. Hemorrhagic complications were confirmed by CT images. Clinical outcomes were evaluated using the modified Rankin scale (mRS), with scores of 0–2 indicating favorable outcomes and scores above 2 denoting poor outcomes.

Angiographic and clinical outcomes were assessed by two neurointerventionalists with 5 years of experience in endovascular treatment, who independently reviewed the images and were blinded to patient details. Any discrepancies were resolved by a third neurointerventionalist with 10 years of experience in the field.

Statistical analysis

Statistical analyses were conducted using R version 4.1.2 (The R Foundation, Vienna, Austria) and SPSS software version 25 (IBM Corp, Armonk, New York, USA). The Shapiro-Wilk test was used to assess the normality of continuous data. Continuous variables were presented as means ± standard deviations (SD). Normally distributed continuous variables were compared using the unpaired t-test, whereas non-normally distributed variables were analyzed using the Wilcoxon rank-sum test. Categorical variables were expressed as counts with percentages and compared using the χ² test or Fisher’s exact test. PSM was applied to equilibrate the groups, with propensity scores estimated based on age, sex, smoking, alcohol consumption, hypertension, aneurysm location, maximum diameter, neck size, and dome-to-neck ratio. Patients were matched at a 1:1 ratio using the nearest-neighbor method and a caliper width of 0.1 of the SD of the logit of the propensity score. Stratification variables were selected based on aneurysm characteristics that are likely to influence treatment outcomes, including parent vessel diameter, dome-to-neck ratio, and aneurysm location (e.g., bifurcation vs. sidewall aneurysms). P<0.05 was considered statistically significant.

Results

Patient and aneurysm characteristics

A total of 572 consecutive patients (572 intracranial aneurysms) were recruited, of whom 373 (65.2%) were females. The overall mean age was 58.2±9.6 years. Among these patients, 159 (27.8%) received treatment with EP2 stent, whereas 413 (72.2%) underwent treatment with the Neuroform Atlas stent. Except for differences in age, gender, history of hypertension, smoking, and alcohol consumption, baseline characteristics were comparable between the two groups. The baseline characteristics of patients are detailed in Table 1. Compared with the EP2 stent, the Neuroform Atlas stent was more frequently used for aneurysms in the middle cerebral artery, anterior communicating artery, and anterior cerebral artery (35.4% vs. 22.0%, P=0.006) and bifurcation aneurysms (78.2% vs. 20.1%, P<0.001) but less commonly used for aneurysms with larger parent vessel diameters (2.72 vs. 3.56 mm, P<0.001) and higher dome-to-neck ratios (1.08 vs. 1.31, P<0.001).

Procedure details

All EP2 stents were placed successfully on the first try. Approximately 99.8% (412/413) of patients in the Neuroform Atlas group had successful first-attempt stent placement, with only one patient requiring an adjuvant balloon to adjust the stent after initial deployment. Fifteen patients (3.6%) required two partially overlapping Neuroform Atlas stents, whereas non-overlapping placement was preferred with EP2 stents (3.6% vs. 0.0%, P=0.032). In the Neuroform Atlas group, 66.4% of stents deployed were 3 mm in width, with sizes ranging from 3.0×15 to 4.5×30 mm. In contrast, the EP2 group only used 5 mm width stents, ranging from 16 to 39 mm in length. Although the Neuroform Atlas stent is more commonly used for bifurcation aneurysms and the EP2 stent is more commonly used for sidewall aneurysms, the median number of coils used in both groups was 5 (P=0.999). The procedure time was slightly shorter for the Neuroform Atlas group than for the EP2 group (124.5±32.4 vs. 134.1±40.5 minutes, P=0.011). Additionally, the total hospital cost was lower for the EP2 group than for the Neuroform Atlas group ($25,349.0±6,406.9 vs. $26,674.3±6,814.6, P=0.036). No significant differences were found between the groups in the remaining factors.

Perioperative and follow-up outcomes

Angiographic and clinical outcomes between Neuroform Atlas and EP2 stents before and after PSM are shown in Table 2. The overall rate of perioperative ischemic complications was 5.9% (34/572). Specifically, the Neuroform Atlas group had 18 cases (4.4%) of perioperative ischemic complications, including 8 cases of cerebral infarction, 8 cases of TIA, and 2 cases of stent thrombosis. This was significantly lower than the 16 cases (10.1%) in the EP2 group, including 10 cases of cerebral infarction, 4 cases of TIA, and 2 cases of stent thrombosis (P=0.017). Both groups had a perioperative hemorrhagic complication rate of 1.9% (P=0.999). No significant differences were observed between the two groups regarding the follow-up duration (8.3±2.4 vs. 8.7±5.9 months, P=0.306) or recanalization rates (4.6% vs. 4.4%, P=0.999). Although immediate postoperative angiography showed a significantly higher complete occlusion rate of aneurysms in the Neuroform Atlas group than in the EP2 group (87.9% vs. 76.7%, P=0.001), no significant difference was found in the 8-month follow-up (89.3% vs. 87.4%, P=0.613). Postoperative neurological functional outcomes were comparable between the groups (1.7% vs. 1.9%, P=0.999). However, the Neuroform Atlas group had significantly better neurological outcomes than the EP2 group at follow-up (0.5% vs. 3.1%, P=0.03).

PSM analysis

An adjustment for age, sex, smoking, drinking, hypertension, aneurysm location, maximum diameter, neck size, and dome-to-neck ratio yielded 147 matched pairs. After PSM, the two groups were well-matched regarding characteristics (Table 1). Compared with EP2 stents, Neuroform Atlas stents showed a significant tendency to be used for smaller parent vessel diameter aneurysms (2.9±0.8 vs. 3.6±0.9 months, P<0.001) and bifurcation aneurysms (72.1% vs. 21.1%, P<0.001). The hospitalization expenses of the EP2 group were significantly lower than those of the Neuroform Atlas group ($25,235.9±6,484.2 vs. $27,540.5±7,125.9, P=0.004). No significant differences were detected between the Neuroform Atlas and EP2 groups regarding the immediate aneurysm occlusion rate (87.1% vs. 79.6%, P=0.118), follow-up occlusion rate (89.1% vs. 87.1%, P=0.719), perioperative ischemic complications (6.8% vs. 10.2%, P=0.403), perioperative hemorrhagic complications (2.0% vs. 2.0%, P=0.999), or neurological outcomes (1.4% vs. 3.4%, P=0.444) (Table 2).

Subgroup analyses

Subsequently, aneurysms were compared based on parent vessel diameter, dome-to-neck ratio, and bifurcation location to evaluate the effect of stent selection on complications and neurological outcomes under different aneurysm characteristics. The Neuroform Atlas stent was linked to significantly lower perioperative ischemic complications in aneurysms with a parent vessel diameter <3.5 mm (4.2% vs. 14.7%, P=0.003). However, no significant difference was found between Neuroform Atlas and EP2 stents regarding neurological function prognosis at follow-up (1.8% vs. 2.9%, P=0.626) or perioperative hemorrhagic complications (0.6% vs. 1.5%, P=0.425). Meanwhile, the Neuroform Atlas stent showed significantly lower perioperative ischemic complications than the EP2 stent for aneurysms with a dome-to-neck ratio greater ≥1 (4.9% vs. 11.4%, P=0.025). No significant differences were observed between Neuroform Atlas and EP2 stents regarding neurological function prognosis at follow-up (0.9% vs. 3.0%, P=0.201) or perioperative hemorrhagic complications (2.2% vs. 2.3%, P=0.999). The Neuroform Atlas stent achieved significantly lower perioperative ischemic complications than the EP2 stent for bifurcation aneurysms (4.3% vs. 21.9%, P=0.001). However, no significant difference was observed between Neuroform Atlas and EP2 stents regarding neurological function prognosis at follow-up (0.6% vs. 3.1%, P=0.247) or perioperative hemorrhagic complications (2.2% vs. 3.1%, P=0.534). Representative cases of bifurcation aneurysms treated with each stent type are presented in Figure 1. All subgroup comparisons showed no significant differences after PSM. PSM results before and after matching between Neuroform Atlas and EP2 groups are presented in Table 3.

Figure 1 Representative images of bifurcation aneurysms treated with Neuroform Atlas and EP2 stents. (A) Three-dimensional rotational angiography showing a bifurcation aneurysm at the left MCA. (B) Pre-treatment angiography of the aneurysm. (C) Complete aneurysm occlusion after treatment with an EP2 stent; black arrows indicate the proximal and distal ends of the EP2 stent. (D) Computed tomography angiography at 30-month follow-up demonstrates complete aneurysm occlusion and patency of the parent artery. The red box indicates complete occlusion of the aneurysm at follow-up in the EP2 group. (E) Three-dimensional rotational angiography showing a bifurcation aneurysm at the right MCA. (F) Pre-treatment angiography of the aneurysm. (G) Complete aneurysm occlusion after treatment with a Neuroform Atlas stent; white arrows indicate the proximal and distal ends of the Atlas stent. (H) Follow-up angiography at 13 months shows complete occlusion of the aneurysm and preservation of parent artery patency. The white box indicates complete occlusion of the aneurysm at follow-up in the Atlas group. EP2, Enterprise 2; MCA, middle cerebral artery.

Discussion

Key findings

SAC is one of the most popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios. Neuroform and Enterprise stents are the most widely used intracranial stents for SAC. In recent years, their latest generation stents Neuroform Atlas and EP2 have been widely used for treating wide-necked aneurysms. The current retrospective single-center study compared Neuroform Atlas and EP2 stents and revealed the following key findings. First, SAC using the EP2 stent for treating anterior circulation aneurysms had the advantage of lower hospital costs than the Neuroform Atlas. In addition, the rates of complete aneurysm occlusion, complications, and good prognosis at follow-up were comparable between the two devices. Nevertheless, the Neuroform Atlas stent showed a trend toward better neurological function prognosis and a lower incidence of ischemic events, which was statistically significant before PSM. Moreover, subgroup analysis revealed that Neuroform Atlas stents were more commonly used for aneurysms with smaller parent vessel diameters and bifurcation aneurysms, showing a trend toward reducing ischemic events. Conversely, the EP2 stent was more frequently used for aneurysms with a larger dome-to-neck ratio, with a higher tendency for ischemic events. To the best of our knowledge, this is the first study to comprehensively compare the characteristics and medium-term outcomes of SAC using Neuroform Atlas and EP2 stents.

Comparison of previous studies of the Neuroform Atlas stent for intracranial aneurysm with the results of the present study

Recently, numerous studies have evaluated the efficacy of Neuroform Atlas stents for intracranial aneurysms. The complete occlusion rate of Neuroform Atlas treatment ranged from 84.7% to 89.9% and the incidence of ischemic complications ranged from 3.3% to 7.6% in several large prospective trials (5,8,11). Similarly, a retrospective study by Caragliano et al. of 113 patients reported that rates of occlusion and good neurological function prognosis at follow-up were 82% and 96.5%, respectively (12). Consistent with the findings of previous studies, the results of the present study showed that the Neuroform Atlas stent was commonly used for anterior communicating arteries and middle cerebral aneurysms in the anterior circulation, as it is soft enough to pass through small and highly tortuous vessels.

Comparison of previous studies of the EP2 stent for intracranial aneurysm with the results of the present study

The EP stent has been widely applied in SAC procedures globally. Compared with EP stent, the EP2 stent offers enhanced stent compliance and improved marker visibility. Recent studies, albeit with limited sample sizes, have reported favorable outcomes when employing EP2 for intracranial aneurysms. Wu et al. (13) found that 83.67% (82/98) of patients with paraclinoid aneurysms treated with EP2 stent-assisted embolization therapy achieved complete occlusion at follow-up, and 95.92% (94/98) had good neurological function prognosis. Chen et al. (9) reported that complete occlusion was achieved in 95.7% of aneurysms at follow-up without perioperative complications. The findings of the current study are congruous with the results of previous reports, except for a higher perioperative ischemic complication rate (10.2%).

Comparison between Neuroform Atlas and EP2 stents for intracranial aneurysm

The Neuroform Atlas stent with an open-cell design provides higher radial force and improved stability (14). Additionally, its compatibility with a 0.165-inch inner diameter microcatheter enhances its versatility, enabling the treatment of aneurysms in more challenging and distal locations and tortuous vascular segments (5). Iwakami et al. (15) compared the mechanical properties of different stents and found that the Neuroform Atlas exhibited lower radial force and compressive strength than the EP2, but performed better in terms of conformability, which may enhance its adaptability and deployment in small vessels. Ozaki et al. (16) reported on the use of the Neuroform Atlas stent for coil embolization of unruptured cerebral aneurysms in arteries with diameters smaller than 2 mm. Their study demonstrated that Neuroform Atlas showed good efficacy and feasibility in these small vessels. Our findings also showed that Neuroform Atlas stents were more commonly used for aneurysms with smaller anterior circulation distal parent vessels and had a lower incidence of perioperative ischemic complication rate than EP2 stents for aneurysms with a parent vessel diameter <3.5 mm (7.1% vs. 14.3%, P=0.121), which was significantly different before matching. The EP2 stent with a closed-cell design allows for recapture and repositioning, including complete withdrawal and ovalization in curved vascular segments. This design ensures that coils remain within aneurysms, thereby protecting the parent artery. However, the incomplete stent apposition is associated with its closed-cell design and the vessel angle (17).

Incomplete stent apposition poses risks of delayed ischemic events after SAC. The present study found that the Neuroform Atlas group more often deployed 3 mm width stents (66.4%), with sizes ranging from 3.0 × 15 mm to 4.5 × 30 mm, while the EP2 group only deployed 5 mm width stents, larger than the four widths of the Neuroform Atlas stent, with lengths ranging from 16 to 39 mm. Notably, the EP2 stent has been increased from 4.5 to 5 mm in the first generation to improve stent-vessel wall apposition. An in vitro study found that the EP2 stent achieved better vessel wall apposition than the EP stent (18). However, a study using three-dimensional fusion imaging in patients who underwent SAC for intracranial aneurysms found that the Neuroform Atlas stent exhibited better apposition than both EP2 and Neuroform EZ stents (19). The complex physiological bending of blood vessels encountered in vivo may explain the less satisfactory outcomes in stent placement in real-world clinical settings than in in vitro experiments.

It has also been demonstrated that while the EP2 stent generally performs well, it exhibits malapposition in vessels with strong curvature (9,19), consistent with the findings of the present study, which found a significantly higher perioperative ischemic complication rate in the EP2 group than the Neuroform Atlas group for bifurcation aneurysms (21.9% vs. 4.3%, P=0.001). This trend persisted even after PSM (19.4% vs. 7.5%, P=0.086), suggesting that the poorer performance of the EP2 stent in treating bifurcation aneurysms may be the primary factor contributing to the overall higher perioperative ischemic complication rate observed in the EP2 group. Wide-necked bifurcation aneurysms are particularly challenging, and the high proportion of bifurcated aneurysms (62.1%) in the current study likely contributed to a higher overall perioperative ischemic complication rate. Another potential factor is that data collection was limited to the first year after the introduction of the two stents, during which proficiency with the new generation of stents was still developing. Our subgroup analysis revealed that the perioperative ischemic complication rate for wide-neck aneurysms with a dome-to-neck ratio >1, indicating a relatively small neck, was lower for the Neuroform Atlas stent than for the EP2 group (8.0% vs. 11.7%, P=0.367), with a significant difference observed before matching (4.9% vs. 11.4%, P=0.025).

Overall, the present PSM study demonstrated that the EP2 and Neuroform Atlas stents exhibited comparable efficacy after adjusting for baseline differences in patient and aneurysm characteristics. Both stent types achieved high occlusion rates and favorable clinical outcomes. The primary distinction between the two methods is cost efficiency and application versatility. The EP2 stent is inexpensive and may be more suitable for aneurysms with smaller necks and less complex anatomy, whereas the Neuroform Atlas stent is more versatile, particularly for distal carotid artery aneurysms with smaller parent artery diameters and bifurcation aneurysms. For these types of aneurysms, the Neuroform Atlas stent also achieved lower perioperative ischemic complication rates than the EP2 stent.

Limitations

There are several limitations in this study. First, the retrospective design of this study introduces risks such as incomplete data, recall bias, and unidentified confounding factors. Although PSM was employed to control for baseline biases, unmeasured confounders and overlooked factors may still have influenced the final results. For instance, varying levels of surgeon proficiency with each stent may affect their selection. Second, this study did not use VasoCT technology to observe stent apposition, which may provide more precise information on stent placement. In addition, because the Neuroform Atlas and EP2 were introduced at different times in our center, we limited the analysis to the first year after introduction of each stent to reduce imbalance between the groups. With advancing surgical techniques and increased operator experience, future research may provide a more equitable comparison between the two devices, particularly with extended follow-up periods. This would help address the limitations of our 1-year study design, offering more insight into long-term outcomes and the devices’ performance over time. Third, the follow-up duration was insufficient to capture long-term changes in occlusion rates and clinical outcomes, which should be assessed over a more extended period. Finally, some subgroups had limited sample sizes, which may limit statistical power. Therefore, a prospective trial with a large number of random samples and long-term follow-up is required to validate our conclusions.

Conclusions

In summary, this PSM study demonstrated that Neuroform Atlas and EP2 stents achieved high occlusion rates with positive clinical outcomes. Besides, EP2 stents are more economical, while fewer ischemic complications were observed with the Neuroform Atlas, particularly for treating distal carotid artery aneurysms with smaller parent artery diameters and bifurcation aneurysms.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-595/rc

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-595/dss

Funding: This work was supported by the National Natural Science Foundation of China (grant No. 82371315), National Health Commission of The People’s Republic of China (grant No. GWJJ2022100104).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-595/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was approved by the Institutional Review Board of Beijing Tiantan Hospital (No. QX2019-009-10) and all participants gave informed consent before taking part. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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