© 2017 by the Congress of Neurological Surgeons. BACKGROUND: To date, the use of the flow-diverting Pipeline Embolization Device (PED) for small intracranial aneurysms (= 7 mm) has been reported only in single-center series. OBJECTIVE: To evaluate the safety and efcacy of the PED in a multicenter cohort. METHODS: Five major academic institutions in the United States provided data on patient demographics, aneurysm features, and treatment characteristics of consecutive patients with aneurysms = 7 mm treated with a PED between 2009 and 2015. Radiographic outcome was assessed with digital subtraction angiography. Clinical outcome was measured with the modifed Rankin Scale. RESULTS: The cumulative number of aneurysms = 7 mm treated with PED at the 5 institutions was 149 in 117 patients (age, 54 years [range, 29-87 years]; male to female, 1-5.9). Aneurysms were most commonly located in the paraophthalmic segment (67.1%) of the internal carotid artery. Radiographic outcome at last follow-up was available for 123 aneurysms (82.6%), with a complete occlusion rate of 87%. Thromboembolic and symptomatic procedural complications occurred in 8.7% and 6% of the aneurysms treated, respectively. There was 1 mortality (0.9%) unrelated to the PED procedure. Multivariable logistic regression identifed size < 4 mm, balloon angioplasty to open the device, and simultaneous treatment of multiple aneurysms as predictors of procedural complications. Good clinical outcome was achieved in 96% of electively treated patients. CONCLUSION: In the largest series on PED for small aneurysms to date, data suggest that treatment with the flow-diverting PED is safe and efcacious, with complication rates comparable to those for traditional endovascular techniques.