BlueCross BlueShield of Tennessee Medical Policy Manual

Angioplasty or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)


Intracranial arterial disease includes vascular stenoses and aneurysms located in the internal carotid, middle cerebral, vertebral or basilar arteries. Minimally invasive endovascular treatment options have been investigated for intracranial aneurysm and atherosclerosis.

Aneurysms are caused by a weakness in the artery wall, causing dilatation or ballooning of the vessels. Thinning of the vessel and the pressure of continuous blood flow may cause the aneurysm to enlarge and rupture and/or hemorrhage. Intracranial aneurysms have been treated by surgical ligation and clipping; however, some aneurysms are located in areas that are difficult to access. Detachable coil embolization procedures have been introduced as a minimally invasive alternative for these hard to reach areas. Stent-assisted coiling and the use of flow-diverting stents are proposed as an alternative to endovascular coiling in individuals whose anatomy is not amenable to simple coiling.

Atherosclerotic stenosis is a potentially life threatening disorder which can lead to an ischemic stroke. 

It is estimated that intracranial atherosclerosis causes about 8% of all ischemic strokes. Intracranial stenosis may contribute to stroke in two ways: either due to embolism or low-flow ischemia in the absence of collateral circulation. Medical treatment typically includes either anticoagulant therapy or antiplatelet therapy. Percutaneous transluminal angioplasty (PTA) has been investigated for the prophylaxis or treatment of symptomatic atherosclerotic stenosis of intracranial arteries.  PTA (e.g. Neurolink System®, Wingspan™ Stent System) involves inserting an inflatable balloon catheter into a narrow or stenosed vessel to dilate and recanalize the vessel.

Note: This policy does not address the use of endovascular mechanical embolectomy for acute ischemic stroke or rescue endovascular therapies, including intra-arterial vasodilator infusion and intracranial percutaneous transluminal angiography, in delayed cerebral ischemia after aneurysmal hemorrhage.





In 2011, the Pipeline® Embolization Device, an intracranial aneurysm flow diverter, was approved by FDA through the premarket approval process for the endovascular treatment of adults with large or giant wide-necked intracranial aneurysms in the internal carotid artery. Three stents have received FDA approval through the humanitarian device exemption (HDE) program for treatment of intracranial aneurysms for use with embolic coils. They are the Neuroform™ Microdelivery Stent System, the Enterprise® Vascular Reconstruction Device and Delivery System, and the Low-Profile Visualized intraluminal Support Device™.


American Heart Association, American Stroke Association. (2015). Guidelines for the management of patients with unruptured intracranial aneurysms. Retrieved July 10, 2019 from

BlueCross BlueShield Association. Evidence Positioning System. (5: 2019). Endovascular procedures for intracranial arterial disease (atherosclerosis and aneurysms) (2.01.54). Retrieved July 9, 2019 from  (104 articles and/or guidelines reviewed)

Briganti, F., Leone, G., Marseglia, M., Mariniello, G., Caranci, F., Brunetti, A., et al. (2015). Endovascular treatment of cerebral aneurysms using flow-diverter devices: a systemic review. Neuroradiology Journal, 28 (4), 365-375. Abstract retrieved July 10, 2019 from PubMed database.

Cagnazzo, F., Cappucci, M., Lefevre, P.H., Dargazanli, C., Gascou, G., Morganti, R., et al. (2018). Treatment of intracranial aneurysms with self-expandable braided stents: a systematic review and meta-analysis. American Journal of Neuroradiology, 39 (11), 2064-2069. Abstract retrieved July 10, 2019 from PubMed database.

Centers for Medicare & Medicaid Services. (2013, March). NCD for percutaneous transluminal angioplasty (PTA) (20.7). Retrieved October 15, 2015 from

National Institute for Health and Clinical Excellence (NICE). (2012, July). Endovascular stent insertion for intracranial atherosclerotic disease, IPG 429. Retrieved February 11, 2013 from

National Institute for Health and Clinical Excellence (NICE). (2012, May). Pipeline embolisation device for the treatment of complex intracranial aneurysms. Retrieved April 29, 2014 from

Patzig, M., Forbrig, R., Ertl, L., Brückmann, H., & Fesl, G. (2017). Intracranial aneurysms treated by flow-diverting stents: long-term follow-up with contrast-enhanced magnetic resonance angiography. Cardiovascular and Interventional Radiology, 40 (11), 1713-1722. Abstract retrieved July 31, 2017 from PubMed database.

U. S. Food and Drug Administration. (2002, August). Center for Devices and Radiological Health. NEUROLINK® system - H010004. Retrieved February 11, 2013 from

U. S. Food and Drug Administration. (2005, August). Center for Devices and Radiological Health. Wingspanstent system with Gateway™ PTA balloon catheter - H050001. Retrieved February 11, 2013 from

U. S. Food and Drug Administration. (2005, August). Center for Devices and Radiological Health. Cordis Enterprisevascular reconstruction device and delivery system - H060001. Retrieved April 29, 2014 from

U.S. Food and Drug Administration. (2002, September). Center for Devices and Radiological Health. Neuroform microdelivery stent system – H020002. Retrieved April 29, 2014 from

U.S. Food and Drug Administration. (2011. April). Center for Devices and Radiological Health. Pipeline embolization device. Retrieved April 29, 2014 from

Winifred S. Hayes, Inc., Medical Technology Directory. (2017). Flow diverter devices for intracranial aneurysms: a review of reviews. Retrieved July 31, 2017 from (43 articles and/or guidelines reviewed)

Zhou, G., Su, M., Yin, Y., & Li, M. (2017). Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurgical Focus, 42 (6), E17. (Level 2 evidence)

Zhu, D., Yan, Y., Zhao, P., Duan, G., Zhao, R., Liu,. J., & Huang, Q. (2018). Safety and efficacy of flow diverter treatment for blood blister-like aneurysm: a systematic review and meta-analysis. World Neurosurgery, 118, e79-e86. Abstract retrieved July 10, 2019 from PubMed database.




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