Elective flow diversion is among the most standardized and technically controlled procedures in neurovascular intervention. Precisely because of that, says Dr. David Fiorella, Director of the Cerebrovascular Center at Stony Brook University Hospital, there should be zero tolerance for planning errors.

At ESMINT 2025, Dr. Fiorella presented how his team has integrated clinical decision-support tools into their elective flow diversion workflow, helping streamline preparation, improve device selection consistency, and strengthen collaboration during planning.
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Precision in Device Selection

According to Dr. Fiorella, the most critical cognitive step in flow diversion is selecting the right device diameter and length. Small mismatches between device and vessel geometry can result in proximal overhang, device malapposition and sometimes a requirement for multiple device placement when a single (optimally sized) device might have sufficed, all of which can complicate treatment.

Dr. Fiorella’s approach centers on meticulous preparation and first-attempt accuracy: selecting the optimal device the first time and achieving full apposition across the aneurysm neck. This philosophy has led his team to integrate a structured planning workflow using Ankyras®, a CE-marked and FDA-cleared clinical decision-support application from Mentice.

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Planning with Ankyras®

Ankyras® supports pre-operative planning for flow diversion by modeling device sizing, placement, and expansion on patient-specific 3D angiographic data. By uploading DICOM angiography data to the software, the team can visualize device configurations, explore different landing zones, and assess predicted expansion through color-coded heatmaps that represent vessel fit.
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 “Once you start using it, you realize how extraordinarily helpful it is,” says Dr. David Fiorella. “It essentially removes the unnecessary uncertainty regarding optimal device selection and positioning.”

At Stony Brook, technologists upload the imaging data and generate simulations ahead of each procedure. When Dr. Fiorella enters the angio suite, multiple device options have already been pre-visualized. This process helps the team focus entirely on execution rather than measurements or adjustments during treatment.
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“It doesn’t slow us down, in fact, now that we have integrated it into routine practice, it considerably speeds us up. I can walk into the room, and everything’s ready to go.”

Structured Planning, Consistent Outcomes

Integrating software-based planning has given the Stony Brook team a more reproducible and collaborative workflow. Each case now follows a standardized preparation process that allows the clinical team to review and discuss device options in advance, reducing intra-procedural uncertainty.

The software also provides a visual feedback loop after treatment. By comparing the deployed device on post-procedural imaging with the predicted length from Ankyras®, the team gains clear visual insight into whether areas of malapposition may be present along the device. When the deployed device appears longer than predicted, it can indicate incomplete expansion, information that can guide the team in identifying potential regions of malapposition for targeted angioplasty.

Since adopting Ankyras®, the Stony Brook team has applied it in more than 75 consecutive elective flow diversion cases, refining their device selection process and aligning procedural planning across the entire team.

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Seamless Integration into Clinical Practice

According to Dr. Fiorella, one of the greatest advantages of Ankyras® is its ease of integration. The software fits naturally into existing imaging workflows and can be operated by technologists after minimal training.
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“It’s seamlessly integrated into our workflow at this point,” says Dr. Fiorella.

The application’s accessibility also facilitates communication between physicians, technologists, and nurses, ensuring that everyone enters the procedure with a shared understanding of the device plan and anatomical context.

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Toward More Informed and Predictable Planning

As endovascular treatment continues to evolve, tools like Ankyras® are helping physicians visualize and evaluate device behavior before entering the angio suite, bringing greater predictability and confidence to each step of the workflow.

“If I were running a clinical trial on flow diversion,” says Dr. Fiorella, “I’d want every operator using something like this.”

Watch the full presentation:
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‍Discover how Ankyras® is used to support virtual device planning in flow diversion procedures, helping clinicians assess device sizing, placement, and anatomical fit before treatment.

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About Dr. David J. Fiorella

Dr. Fiorella is Director of the Cerebrovascular Center and Professor of Neurosurgery and Radiology at Stony Brook University Hospital. A pioneer in neuro-interventional therapies, he has led multiple clinical trials advancing endovascular devices for the treatment of aneurysm, stroke, and hemorrhage.

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Disclaimer and Regulatory Information

These reflections represent the clinician’s own perspectives and experiences shared during his presentation, focused on clinical workflow. *
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Ankyras® is manufactured by Mentice Spain S.L. ANKYRAS is a medical software intended to assist healthcare professionals in the selection of a proper braided device for the treatment of intracranial aneurysms. Ankyras complies with the Medical Device Regulation (EU CE Mark, MDR 784032, Class IIb, ON 2797). Ankyras is notified to ANVISA (registration number 81118630030) and cleared by the FDA under 510(k) number K250160. Mentice Spain S.L. is ISO 13485 certified with number MD 784027. All operators must read the complete Instructions for Use before operating the ANKYRAS. ANKYRAS is intended for exclusive use by professional users. Mentice subsidiaries and partners distribute the medical software products developed and manufactured by Mentice Spain S.L.

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