Preprocedural antiplatelet therapy and intraprocedural anticoagulation are widely accepted methods to avoid thromboembolic events that may occur during or after an endovascular procedure for unruptured intracranial aneurysms¹⁾. However, in a particular population lacking adequate hemostasis, there may be a hesitation in adopting the conventional periprocedural antithrombotic management concerning the procedure-related hemorrhagic risk. Thrombocytopenia and hemostatic failure are common conditions in liver cirrhosis (LC) patients²⁾. Although many studies have assessed procedure-related bleeding risk and periprocedural management in LC patients, there are no established guidelines for periprocedural hemostatic management in LC patients with thrombocytopenia, especially before neurointerventional procedures²⁾. Herein, we report a case of successful endovascular coiling of an unruptured intracranial aneurysm (UIA) in a LC patient with severe thrombocytopenia. We also studied the appropriate periprocedural and intraprocedural management for UIA coiling in LC patients with hemostatic defects.

A female patient in her early 60s visited the outpatient department complaining of a chronic headache. Computed tomography (CT) angiography revealed a saccular aneurysm at the bifurcation of the left middle cerebral artery with 6.0 mm of maximal diameter and 3.8mm of neck size (Fig. 1). The patient had nonalcoholic decompensated LC with a Child–Turcotte–Pugh score of 8 and was, categorized as class B. Laboratory tests revealed severe thrombocytopenia (30,000cells/µL), International normalized ratio (INR) of 1.22, activated partial thromboplastin time (aPTT) of 38.3 seconds (normal range of 28.0–45.0 seconds in our institution), and a fibrinogen level of 230 mg/dL (normal range of 190–450 in our institution). Considering the life expectancy of this patient with decompensated LC, observation of this unruptured aneurysm was also an option. However, the decision to treat the aneurysm was made due to the expectations of liver transplantation and the patient's fear of aneurysmal rupture. Endovascular coiling was planned, considering the patient's medical condition.

The traditional thresholds of platelet count > 50,000/µL and INR < 1.5 have been accepted for the safety of major surgery³⁾. Based on literature on successful endovascular coiling of UIA in a patient with idiopathic thrombocytopenic purpura (ITP) with periprocedural platelet count of 53,000/µL, we decided to normalize the thrombocytopenia as much as possible, aiming for a platelet count > 50,000/µL⁴⁾. Detailed blood transfusion procedures were performed in accordance with the Korean domestic blood transfusion guidelines. Eight pints of platelet concentrate were transfused 6 hours before the procedure, and a platelet count of 57,000/µL was achieved 3 hours before the procedure. No perioperative antiplatelet therapy was administered. Considering the shape of the aneurysm based on the CT angiography findings, simple coiling without an adjunctive device was planned. Off-label, bail-out use of Tirofiban (Aggrastat^®) administration was prepared if rescue stenting was required or an inadvertent intraprocedural thromboembolic event occurred. Coiling was performed under general anesthesia, and systemic heparinization was not performed. Heparinized saline was used only for device preparation. A 6 French Envoy DA XB (Cordis, Miami Lakes, FL, USA) guiding catheter was advanced through a 7 French femoral sheath (Terumo, Tokyo, Japan). The aneurysm was selected using an SL-10 pre-shaped S microcatheter (Stryker, Fremont, CA, USA). Catheters and wires were navigated with extreme caution. Six detachable coils (Stryker, Fremont, CA, USA) were deployed, and complete aneurysm occlusion was achieved (Fig. 2). The arterial puncture site was closed using a suture-mediated device (Perclose; Abbott Vascular, CA, USA). The procedure was performed successfully without any copmlications. Diffusion magnetic resonance (MR) image acquired on the first postoperative day revealed multiple high embolic signals; however, the patient was asymptomatic (Fig. 3). The hospital course was uneventful, and the patient was discharged with a modified Rankin Scale score of 0. A 6-month follow-up MR angiography showed no evidence of recanalization, and the patient's general medical condition remained unchanged.

A highly individualized approach is needed for hemostatic management of LC patients with severe thrombocytopenia before UIA coiling. We suggest prophylactic transfusion to achieve a platelet count > 50,000/μL and an INR < 1.5. Bail-out use of tirofiban for inadvertent intra- or postoperative thromboembolism may be considered for patients with hemostatic failure.