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.
Endovascular therapies, including percutaneous transluminal angioplasty with or without stenting, for the treatment or management of extracranial vertebral artery disease is considered investigational.
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We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
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.
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
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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