BlueCross BlueShield of Tennessee Medical Policy Manual

Endovascular Therapies for Extracranial Vertebral Artery Disease

DESCRIPTION

Vertebral artery diseases, including atherosclerotic stenosis, dissections and aneurysms, can lead to ischemia of the posterior cerebral circulation.  Conventional management of extracranial vertebral artery diseases may include medical therapy such as antiplatelet or anticoagulant medications, medications to reduce atherosclerotic disease risk (e.g., statins), and/or surgical revascularization.  Endovascular therapies, to include percutaneous transluminal angioplasty (PTA) with or without stenting, have been investigated as an alternative to conventional management.

Ischemia of the vertebrobasilar circulation accounts for about 20% of all strokes. Posterior circulation strokes may arise from occlusion of the innominate and subclavian arteries, the extracranial vertebral arteries, or the intracranial vertebral, basilar or posterior cerebral arteries.  Compared with carotid artery disease, relatively little is known about the true prevalence of specific causes of posterior circulation strokes, particularly the prevalence of vertebral artery disease.  Reports from one stroke registry have estimated that, in 9% of cases, posterior circulation strokes are due to stenosis of the proximal vertebral artery.  Individuals who experience strokes or transient ischemic attacks of the vertebrobasilar circulation face a 25 – 35% risk of stroke within the subsequent five years.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Randomized controlled trials have found no advantage for PTA with or without stenting in individuals diagnosed with extracranial vertebral artery stenosis compared to medical therapy alone.  For PTA with stent implantation for extracranial vertebral artery aneurysm(s), dissection(s), and arteriovenous (AV) fistula(e), the evidence includes small case series and case reports.  Given the lack of data comparing endovascular therapies to alternative treatment, the evidence is insufficient to determine the net health outcome.

SOURCES

American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association. (2011) Guideline on the management of patients with extracranial carotid and vertebral artery disease. Retrieved July 14, 2015 from: http://circ.ahajournals.org.

American Heart Association / American Stroke Association. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack. Retrieved May 28, 2015 from: http://stroke.ahajournals.org/.

Antoniou, G., Murray, D., Georgiadis, G., Antoniou, S., Schiro, A., Serracino-Inglott, F., et. al, (2012). Percutaneous transluminal angioplasty and stenting in patients with proximal vertebral artery stenosis. Journal of Vascular Surgery. 55, 1167-77 (Level 1 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2016). Endovascular therapies for extracranial vertebral artery disease. Retrieved May 18, 2017 from BlueWeb. (27 articles and/or guidelines reviewed)

Centers for Medicare & Medicaid Services.CMS.gov. NCD for percutaneous transluminal angioplasty (20.7) Retrieved June 26, 2015 from: http://www.cms.hhs.gov.  

Gulli, G., Marquardt, L., Rothwell, P., & Markus, H. (2013) Stroke risk after posterior circulation stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis. Stroke. 44, 598-604. (Level 2 evidence)

Radak, D., MD, Babic, S., Sagic, D., Tanaskovic,S.,  Kovacevic, V., Otasevic, P. et. al. (2014) Endovascular treatment of symptomatic high-grade vertebral artery stenosis. Journal of Vascular Surgery; 60:92-7. (Level 4 evidence)

Stayman, A., Nogueira, R., & Gupta, R. (2011) A systematic review of stenting and angioplasty of symptomatic extracranial vertebral artery stenosis. Stroke. 42, 2212-2216. (Level 1 evidence)

U. S. Food and Drug Administration. (August 2002) Center for Devices and Radiological Health. Humanitarian Device Exemption (HDE) for Neurolink® System Retrieved May 28, 2015 from: http://www.fda.gov. 

U. S. Food and Drug Administration. (August 2005) Center for Devices and Radiological Health. Humanitarian Device Exemption (HDE) for Wingspan Stent System. Retrieved May 28, 2015 from: http://www.fda.gov. 

ORIGINAL EFFECTIVE DATE: 11/14/2015

MOST RECENT REVIEW DATE:  7/13/2017

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