Management of unruptured intracranial aneurysms in atrial fibrillation: Role of ablation in anticoagulation cessation.

Flow diverters (FDs) are increasingly used for unruptured intracranial aneurysms and require postprocedural dual antiplatelet therapy. In patients receiving oral anticoagulation, such as those with atrial fibrillation (AF), antithrombotic management remains challenging because anticoagulation may impair intra-aneurysmal thrombosis and reduce occlusion rates. We report three AF patients treated with FDs for unruptured intracranial aneurysms. Complete aneurysm occlusion was achieved only in one patient in whom anticoagulation was discontinued after successful catheter ablation combined with ethanol infusion into the vein of Marshall and antiarrhythmic therapy for persistent AF of more than five years. This case series highlights that anticoagulation withdrawal enabled by individualized rhythm-control strategies may facilitate successful FD treatment even in very long-standing persistent AF. Learning objective: To recognize that successful flow diversion in patients with atrial fibrillation may require careful selection of treatment strategies that permit temporary or permanent discontinuation of oral anticoagulation, and to emphasize the importance of individualized, goal-oriented antithrombotic management rather than a fixed anticoagulation approach.