Treatment of cerebral aneurysms with flow diversion or stent assisted coiling in patients on concurrent oral anticoagulation

Abstract

Background: Flow diversion and stent assisted coiling are increasingly utilized strategies in the endovascular treatment of cerebral aneurysms. Ischemic and hemorrhagic complications play an important role in the outcome following such embolizations. Little is published regarding patients on concurrent oral anticoagulation and undergoing such embolizations and the rates of complications and patient outcomes.

Materials and methods: Retrospective data for consecutive patients on concurrent oral anticoagulation undergoing flow diversion or stent assisted coiling for cerebral aneurysms was accessed from databases at the participating sites. Patient demographics, comorbidities, antiplatelet regimens, aneurysm characteristics, complications, and radiographic results were recorded and descriptive statistics reported.

Results: Eleven patients were identified undergoing embolization in the setting of preoperative anticoagulant use and included seven patients undergoing flow diversion and four patients undergoing stent assisted coiling. There was a wide range of antiplatelet and anticoagulant management strategies. There were four major complications in three patients (27.2%) to include two serious bleeding events in addition to ischemic strokes. Both serious bleeding events occurred in patients continued on oral anticoagulation with the addition of antiplatelets. At a mean follow-up of 9.6 months, three aneurysms had continued filling for a good radiographic outcome of 72.7%.

Conclusions: Anticoagulant and antiplatelet use in the setting of flow diversion or stent assisted coiling may carry increased risks as compared to historical norms and, for flow diversion, offer decreased efficacy.

Keywords: aneurysm; anticoagulation; embolization.

Figure 1.

Pre- (a) and post-embolization late venous phase (b) angiography showing a left posterior communicating artery aneurysm treated with flow diversion in a patient on apixaban and concurrent single antiplatelet therapy with clopidogrel. At 17 months, the aneurysm is occluded (c).