Anterior cerebral artery variants and their influence on endovascular outcomes: a propensity score matched analysis from the CRETA registry

BACKGROUND: Anatomical variants of the anterior cerebral artery (ACA) may increase technical complexity during endovascular treatment of distal ACA aneurysms (DACA). However, their impact on treatment outcomes remains unclear. This study evaluated whether ACA variants influence angiographic and clinical outcomes following endovascular treatment. METHODS: A retrospective multicenter analysis was conducted using data from the CRETA Registry, including patients with ruptured and unruptured DACA treated endovascularly. Patients were grouped according to ACA anatomy (variant vs. conventional). Outcomes were compared after propensity score matching (PSM) to adjust for confounders including age, aneurysm rupture status, dome-to-neck ratio, branch origin, and treatment type. The primary outcome was aneurysm occlusion at last follow-up based on the Raymond-Roy classification. Secondary outcomes included ischemic and hemorrhagic complications, vasospasm, and clinical outcome measured by the modified Rankin Scale (mRS). RESULTS: After PSM, 128 patients were included (64 per group). Among patients with available imaging follow-up (54 in the conventional group and 55 in the variant group), adequate occlusion rates were comparable between the variant and conventional ACA groups (81.5% vs. 85.5%; p = 0.600). No significant differences were observed in ischemic or hemorrhagic complications, vasospasm, or long-term clinical outcomes. Sensitivity analyses confirmed the robustness of the findings. CONCLUSIONS: ACA anatomical variants do not adversely affect the safety or efficacy of endovascular treatment for DACA. With appropriate anatomical assessment and treatment selection, endovascular therapy remains effective even in the presence of complex ACA configurations.