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Objective Accurate flow diverting stent (FDS) sizing is paramount for procedural success in treating intracranial aneurysms. Conventional sizing with angiographic measurements fails to reliably predict stent length or factor in complex vessel-device interactions. Ankyras (Mentice Spain S.L.) is a virtual software that models 3D neurovascular anatomy and simulates stent deployment to guide device selection, sizing, and placement of FDS. We evaluated the accuracy of Ankyras for predicting flow diverter characteristics and present a perioperative workflow for simulation-based aneurysm planning and treatment.Methods A retrospective analysis of a prospectively maintained database was performed of patients who underwent flow diverter (FD) treatment of intracranial aneurysms using Ankyras between April 2024 and October 2025 at Stony Brook University Hospital. Diagnostic 3D rotational angiography data were used to generate patient-specific Ankyras simulations for pre-operative planning, FD device selection, and intraoperative guidance. Ankyras-predicted stent parameters were compared with post-deployment stent centerlines constructed from contrast-enhanced DynaCTs using 3D slicer. Primary endpoints included Ankyras simulated length (SL), deployed stent length (DL), and proximal landing zone (PLZ) between the ICA terminus and proximal stent end. Accuracy was assessed using correlation coefficients, mean absolute error (MAE), and Bland-Altman analysis.Results 53 consecutive patients (48 female, mean age 54.3 years) with 60 unruptured ICA aneurysms underwent 56 Pipeline Embolization Device (PED, Medtronic Neurovascular, Irvine, California, USA) treatments with Ankyras. All cases achieved procedural success without intraoperative complications; two required adjunctive stent placement for malapposition. After excluding cases with indeterminable centerlines due to pre-existing (n=2) or overlapping (n=4) stents, coil mass artifact (n=1), or inadequate DynaCT imaging (n=6), 46 cases were included for stent length and landing zone analyses. Mean SL was 21.44±3.53 mm and DL was 21.49±3.52 mm, with a strong SL-DL correlation (r=0.91), minimal bias (−0.05 mm), and 1.24mm MAE. PLZ predictions also demonstrated strong correlations (r=0.94), low bias (0.14mm), and MAE of 1.34mm between Ankyras and deployed values. Bland-Altman analysis for stent length (mean bias -0.05, 95% agreement limits: -2.93 to 2.84mm) and PLZ (mean bias 0.14mm, 95% agreement limits: -3.20 to 3.49mm) showed excellent agreement between simulated and predicted values, with no systemic shift or proportional bias ( figure 1).Discussion In a prospective clinical cohort, Ankyras demonstrated high accuracy in predicting PED length with a MAE of 1.25mm between simulated and deployed stents. Ankyras-based simulation is a valid and reliable clinical adjunct that enhances device selection and sizing, with great potential to improve procedural precision, consistency, and workflow.Disclosures A. Rheaume: None. S. Mosallami Aghili: None. T. Ang: None. S. Syed: None. S. Iyer: None. C. Denice: None. M. Jean: None. C. Guerrero: None. L. Chojnowski: None. D. Kim: None. T. Tanim: None. E. Birmingham: None. R. Fernandez: None. D. Fiorella: 1; C; Siemens, Microvention, Penumbra, Stryker, Balt USA. 2; C; Mentice, Elixir Medical, Medtronic, Cerenovus, Scientia Medical, RAPID.AI, RAPID Medical, Qapel Medical, Phenox Medical, Vesalio, Perfuze, Microvention, Penumbra, Stryker. 3; C; Perfuze, Arsenal Medical, NVMed, Scientia Medical. 4; C; Perfuze, Arsenal Medical, NVMed, Scientia Medical. 6; C; Medtronic, Microvention.Abstract E-266 Figure 1