A Staged Antithrombotic Strategy Using Preemptive Left Atrial Appendage Occlusion before Flow Diverter Placement: A Case Report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Unruptured large internal carotid artery aneurysm with comorbid paroxysmal nonvalvular atrial fibrillation (n=1). Intervention: Preemptive percutaneous left atrial appendage occlusion (Watchman FLX Pro) followed by DOAC discontinuation, DAPT transition, and flow diverter placement (Pipeline Flex with Shield Technology). Primary outcome: Aneurysm occlusion (O'Kelly-Marotta grade) and LAAO closure stability at 1 year.

Q: What does this research mean for the field?

Preemptive left atrial appendage occlusion enables discontinuation of oral anticoagulation before flow diverter placement for intracranial aneurysms, avoiding prolonged triple antithrombotic therapy while preserving flow diversion efficacy. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Masanobu Kanazawa; Hisayuki Hosoo; Hiro Yamasaki; Shun Tanaka; Koichi Uramaru; Hideaki Matsumura; Takeshi Yoshimoto; Koji Hirata; Yoshiro Ito; Mikito Hayakawa; Aiki Marushima; Hiroshi Yamagami; Yuji Matsumaru

doi:10.5797/jnet.cr.2026-0162

January 1, 2026Journal of Neuroendovascular TherapyOpen Access

A Staged Antithrombotic Strategy Using Preemptive Left Atrial Appendage Occlusion before Flow Diverter Placement: A Case Report

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Why the study?

Flow diverter treatment for intracranial aneurysms requires DAPT, but combining a DOAC and DAPT in patients with AF increases bleeding risk and may attenuate flow diverter-induced intra-aneurysmal thrombosis.

Does a staged antithrombotic strategy using preemptive left atrial appendage occlusion enable direct oral anticoagulant discontinuation and facilitate safe and effective flow diverter placement in a patient with atrial fibrillation and a large unruptured intracranial aneurysm?

Key Points

To describe a staged antithrombotic treatment involving preemptive left atrial appendage occlusion to safely stop direct oral anticoagulants before flow diverter placement in a patient with atrial fibrillation.
Clinical case report of a patient presenting with an unruptured large intracranial aneurysm and concurrent atrial fibrillation managed on a direct oral anticoagulant.
Conducted preemptive left atrial appendage occlusion to permit discontinuation of oral anticoagulation, followed by flow diverter placement under dual antiplatelet therapy.
Preemptive left atrial appendage occlusion successfully facilitated the discontinuation of the direct oral anticoagulant before aneurysm treatment.
Subsequent flow diverter placement proceeded under dual antiplatelet therapy alone, addressing the bleeding risk and potential suppression of intra-aneurysmal thrombosis associated with combined antithrombotic regimens.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does a staged antithrombotic strategy using preemptive left atrial appendage occlusion enable direct oral anticoagulant discontinuation and facilitate safe and effective flow diverter placement in a patient with atrial fibrillation and a large unruptured intracranial aneurysm?

P

Population

1 female patient (age 66) with paroxysmal nonvalvular atrial fibrillation and an unruptured 22-mm cavernous internal carotid artery aneurysm followed for 1 year after flow diverter placement.

I

Intervention

Staged antithrombotic strategy involving a 3rd catheter ablation with LAA angiography (4 months prior to flow diverter), followed by preemptive percutaneous left atrial appendage occlusion (LAAO) using a 24-mm Watchman FLX Pro device (3 months prior to flow diverter). Post-LAAO, oral apixaban 2.5 mg twice daily was continued for 2.5 months, then discontinued 2 weeks before flow diverter placement and transitioned to dual antiplatelet therapy (DAPT) with oral aspirin 100 mg/day and prasugrel 3.75 mg/day (subsequently reduced to 2.5 mg/day due to hyperresponse). A 4.75 × 18-mm Pipeline Flex with Shield Technology flow diverter was deployed across the C3 of the right ICA, with DAPT de-escalated to aspirin monotherapy (100 mg/day) at 5 months post-deployment.

O

Outcome

Aneurysm occlusion (assessed by digital subtraction angiography using the O'Kelly–Marotta grading scale) and LAAO closure stability (assessed by contrast-enhanced CT for peridevice leak or device-related thrombus) at 1 year.surrogate

Preemptive left atrial appendage occlusion is a feasible staged strategy to allow anticoagulation discontinuation prior to dual antiplatelet therapy and flow diverter placement in patients with atrial fibrillation and large unruptured intracranial aneurysms, avoiding triple antithrombotic therapy while preserving flow diverter efficacy.

Limitations

Single-patient case report requiring further clinical experience to clarify optimal patient selection, timing, and antithrombotic protocols.
Neither transesophageal echocardiography nor contrast-enhanced CT was performed before DOAC discontinuation at 2.5 months after LAAO to exclude device-related thrombus or peridevice leak.
Platelet function testing was not repeated after prasugrel dose reduction from 3.75 to 2.5 mg/day.
Neither transesophageal echocardiography nor contrast-enhanced CT was performed before DOAC discontinuation to exclude device-related thrombus or peridevice leak
Optimal antithrombotic protocols following LAAO (exact duration of DOAC continuation, precise timing for DAPT transition, and ideal waiting period before FD placement) remain unclarified
Single patient case report requiring further clinical experience to clarify optimal patient selection and long-term efficacy and safety

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Implication

May inform individualized antithrombotic strategies in high-bleeding-risk patients; leaves open prospective validation of safety and efficacy.

Abstract

Objective: Flow diverter (FD) treatment for intracranial aneurysms requires dual antiplatelet therapy (DAPT). However, in patients with atrial fibrillation (AF) who are taking a direct oral anticoagulant (DOAC), the combined use of a DOAC and DAPT increases bleeding risk and may attenuate FD-induced intra-aneurysmal thrombosis. Here, we report a patient with an unruptured large aneurysm and AF who underwent a staged antithrombotic strategy involving preemptive left atrial appendage occlusion (LAAO) to enable DOAC discontinuation before FD placement.

Discussion

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Cite This Study

Kanazawa et al. (2026) conducted a case report in Unruptured large internal carotid artery aneurysm with comorbid paroxysmal nonvalvular atrial fibrillation (n=1). Preemptive percutaneous left atrial appendage occlusion (Watchman FLX Pro) followed by DOAC discontinuation, DAPT transition, and flow diverter placement (Pipeline Flex with Shield Technology) was evaluated on Aneurysm occlusion (O'Kelly-Marotta grade) and LAAO closure stability at 1 year.

synapsesocial.com/papers/6af9ebcdd393cbc380a04fcb https://doi.org/10.5797/jnet.cr.2026-0162

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A Staged Antithrombotic Strategy Using Preemptive Left Atrial Appendage Occlusion before Flow Diverter Placement: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A Staged Antithrombotic Strategy Using Preemptive Left Atrial Appendage Occlusion before Flow Diverter Placement: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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