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Review ArticleSYSTEMATIC REVIEW/META-ANALYSIS

Impact of Smoking on Recurrence and Angiographic Outcomes After Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis

Sherief Ghozy, Seyed Behnam Jazayeri, Alireza Hasanzadeh, Julien Ognard, Hassan Kobeissi, Ali Ahmadzade, Ehsan Naseh, Mobina Motaghian Fard, Alzhraa S. Abbas, Rachana R Borkar, David F. Kallmes and Ramanathan Kadirvel
American Journal of Neuroradiology February 2025, ajnr.A8712; DOI: https://doi.org/10.3174/ajnr.A8712
Sherief Ghozy
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Seyed Behnam Jazayeri
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Alireza Hasanzadeh
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Julien Ognard
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Hassan Kobeissi
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Ali Ahmadzade
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Ehsan Naseh
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Mobina Motaghian Fard
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Alzhraa S. Abbas
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Rachana R Borkar
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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David F. Kallmes
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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Ramanathan Kadirvel
From the Department of Radiology (S.G.,J.O.,H.K.,D.F.K.,R.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Tehran University of Medical Sciences, Tehran, Iran (S.B.J.,A.H.,A.A.), Department of Neuroradiology, Brest University Hospital, Brest, France (J.O.), Department of Neurosurgery (H.K.), Corewell Health William Beaumont University Hospital, Royal Oak, MI, Iran University of Medical Sciences, Tehran, Iran (E.N., M.M.F.), Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA, and Department of Diagnostic Radiology (R.R.B.), Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut
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ABSTRACT

BACKGROUND: Cerebral aneurysm recurrence serves as a significant endpoint for assessing the efficacy of various endovascular treatment strategies. The impact of smoking on outcomes such as aneurysm occlusion, recurrence, and recanalization remains unclear due to conflicting evidence.

PURPOSE: To systematically evaluate the role of smoking in influencing angiographic outcomes following endovascular treatment of intracranial aneurysms.

DATA SOURCES: Comprehensive searches were conducted in PubMed, Embase, Scopus, and Web of Science

STUDY SELECTION: This systematic review and meta-analysis followed PRISMA guidelines to identify relevant studies assessing smoking's impact on intracranial aneurysms following endovascular treatment.

DATA ANALYSIS: Studies were screened, selected, and assessed for risk of bias using appropriate checklists. Data on complete and adequate aneurysm occlusion, and recurrence/recanalization rates were extracted. Random-effects meta-analyses calculated risk ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was measured using the I2 statistic.

DATA SYNTHESIS: A total of 26 studies, encompassing 6,031 patients, met the inclusion criteria. Smokers had higher rates of complete aneurysm occlusion (RR 1.12, 95% CI 1.06–1.19; p < 0.01). Subgroup analysis revealed that smokers undergoing flow diversion exhibited a higher rate of complete occlusion (RR 1.14, 95% CI 1.07–1.21; p < 0.01). However, for patients undergoing coiling, there was no significant difference in complete occlusion rates between smokers and non-smokers (RR 1.00, 95% CI 0.83– 1.20; p = 0.46). Recurrence/recanalization rates were similar between smokers and non-smokers: RR 1.17, 95% CI 0.93–1.47; p = 0.20, and the rate of aneurysm retreatment did not differ between the smokers and non-smokers: RR 0.82, 95% CI 0.59–1.13; p =0.23.

LIMITATIONS: Heterogeneity in definitions of smoking status, variations in follow-up durations, short follow up, retrospective nature of studies.

CONCLUSIONS: Smoking status does not significantly impact aneurysm recanalization or retreatment after endovascular repair. However, the impact of smoking on complete occlusion rate might differ based on the type of device used for treatment. Histological and molecular factors may contribute to varied outcomes, highlighting the necessity for further research to understand smoking's role in aneurysm healing. Clinically, patients should be advised about the risks of smoking, though current evidence suggests that smoking cessation may not consistently affect treatment efficacy.

ABBREVIATIONS: sAH = subarachnoid hemorrhage; RROC = Raymond-Roy occlusion classification.

Footnotes

  • Equal contribution

  • Disclosure of potential conflicts of interest: D.F.K. holds equity in Nested Knowledge, Superior Medical Editors, and Conway Medical, Marblehead Medical and Piraeus Medical. He receives grant support from MicroVention, Medtronic, Balt, and Insera Therapeutics; has served on the Data Safety Monitoring Board for Vesalio; and received royalties from Medtronic. R.K. has the following conflicts: Research support from: Cerenovus Inc, Medtronic, Endovascular Engineering, Frontior Bio, Sensome Inc, Endomimetics, Ancure LLC, Neurogami Medical, MIVI Biosciences, Monarch Biosciences, Stryker Inc, Conway Medical, Pireus Medical, and Bionaut Labs. He holds the following research grants Research Grants: NIH (R01NS076491, R44NS107111, R43NS110114 and R21NS128199) and NSF (081215707).

  • © 2025 by American Journal of Neuroradiology

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Accepted Manuscript
Sherief Ghozy, Seyed Behnam Jazayeri, Alireza Hasanzadeh, Julien Ognard, Hassan Kobeissi, Ali Ahmadzade, Ehsan Naseh, Mobina Motaghian Fard, Alzhraa S. Abbas, Rachana R Borkar, David F. Kallmes, Ramanathan Kadirvel
Impact of Smoking on Recurrence and Angiographic Outcomes After Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis
American Journal of Neuroradiology Feb 2025, ajnr.A8712; DOI: 10.3174/ajnr.A8712

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Accepted Manuscript
Impact of Smoking on Recurrence and Angiographic Outcomes After Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis
Sherief Ghozy, Seyed Behnam Jazayeri, Alireza Hasanzadeh, Julien Ognard, Hassan Kobeissi, Ali Ahmadzade, Ehsan Naseh, Mobina Motaghian Fard, Alzhraa S. Abbas, Rachana R Borkar, David F. Kallmes, Ramanathan Kadirvel
American Journal of Neuroradiology Feb 2025, ajnr.A8712; DOI: 10.3174/ajnr.A8712
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