BACKGROUND Current evidence comparing flow diverters (FDs) for the treatment of intracranial aneurysms is limited to single‐arm head‐to‐head retrospective and prospective studies. Herein, we aimed to compare the efficacy and safety of four FDs for the treatment of intracranial aneurysms. METHODS We performed a retrospective, multicenter international cohort study of adult patients treated with FDs (Pipeline embolization device, Surpass Streamline, Flow Redirection Endoluminal Device, and Silk) for intracranial aneurysms between 2015 and 2021. Efficacy was determined by aneurysm occlusion at final follow‐up. Safety was determined by ischemic/hemorrhagic events and mortality. Secondary safety was assessed by technical complications. A mixed‐effect multivariable ordinal and logistic regression were performed to evaluate variables that predicted the outcomes of interest. RESULTS We included 235 patients with 274 aneurysms. Treatment was performed with either the Pipeline embolization device (92), Surpass Streamline (56), Flow Redirection Endoluminal Device (47), and Silk (40). Median age was 57 (47–65) years. Most patients were asymptomatic (76%), and 8% had previous rupture. Most aneurysms were saccular (85%) and anterior (94%). The Pipeline embolization device subgroup had the largest aneurysms (6 mm, P =0.005). Median follow‐up time was 9 (6–14) months. Final overall complete occlusion was 72% without significant differences between FDs ( P =0.5). Total ischemic (5%) and hemorrhagic (3%) events were also similar ( P =0.1 and P =0.06). One patient expired (0.4%, P =0.6). In multivariable analysis, device diameter predicted aneurysm persistence and ≥50% in‐stent stenosis predicted ischemic/hemorrhagic complications. CONCLUSIONS Our findings comparing 4commonly used FDs in a heterogeneous population with mainly small‐sized aneurysms confirmed a similar safety and efficacy profile between devices.

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