MEDICAL
POLICY
POLICY TITLE
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR
INTRACRANIAL STENOSIS WITH OR WITHOUT STENTING
POLICY NUMBER
MP-1.089
Original Issue Date (Created):
March 8, 2004
Most Recent Review Date
(Revised):
June 21, 2005
Effective Date:
October 24, 2005- RETIRED
I.
DESCRIPTION/BACKGROUND
It is estimated that intracranial atherosclerosis causes about eight percent (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. Recurrent annual
stroke rates are estimated at four percent (4%) - twelve percent (12%) per year with
atherosclerosis of the intracranial anterior circulation, and two and a half percent (2.5 %) fifteen percent (15 %) per year with lesions of the posterior (vertebrobasilar) circulation.
Medical treatment typically includes either anticoagulant therapy (i.e., warfarin) or
antiplatelet therapy (i.e., aspirin); the relative efficacy of these two drugs in preventing
stroke is currently under study in the randomized WASID trial (Warfarin-Aspirin
Symptomatic Intracranial Disease). In addition, if symptoms are attributed to low flow
ischemia, agents to increase mean arterial blood pressure and avoidance of orthostatic
hypotension may be recommended. However, medical therapy is considered less than
optimal. For example, in patients with persistent symptoms despite antithrombotic therapy,
the subsequent rate of stroke or death is extremely high, estimated in one study at forty-five
percent (45 %), with recurrent events occurring within a month of the initial recurrence.
Surgical approaches have met with limited success. The widely quoted ExtracranialIntracranial (EC/IC) Bypass study randomized 1,377 patients with symptomatic
atherosclerosis of the internal carotid or middle cerebral arteries to medical care or EC/IC
bypass. The outcomes in the two groups were similar, suggesting the EC/IC bypass is
ineffective in preventing cerebral ischemia. Due to inaccessibility, surgical options for the
posterior circulation are even more limited.
Percutaneous transluminal angioplasty (PTA) has been approached cautiously in the
intracranial circulation, due to technical difficulties in catheter and stent design, and the
risk of embolism, which may result in devastating complications if occurring in the
posterior fossa or brain stem. However, improvement in catheter trackability, allowing
catheterization of tortuous veins, and the increased use of stents, has created ongoing
interest in exploring PTA as a minimally invasive treatment of this difficult-to-treat
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MEDICAL
POLICY
POLICY TITLE
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR
INTRACRANIAL STENOSIS WITH OR WITHOUT STENTING
POLICY NUMBER
MP-1.089
population. The bulk of published studies of intracranial PTA have focused on the
vertebrobasilar circulation.
II.
DEFINITIONS
ANTITHROMBOTIC refers to interfering with or preventing thrombosis or blood coagulation.
ATHEROSCLEROSIS is the most common form of arteriosclerosis marked by cholesterollipid-calcium deposits in the walls of the arteries.
ISCHEMIC refers to a temporary deficiency of blood flow to an organ or tissue.
PERCUTANEOUS refers to that which is passed or effected through the skin.
STENOSIS refers to a constriction or narrowing of a passage or orifice.
STENT refers to any material or device used to hold tissue in place, to maintain open blood
vessels, or to provide support for a graft or anastamoses while healing is taking place.
III.
POLICY
Intracranial percutaneous transluminal angioplasty with or without stenting is considered
investigational, as there is insufficient evidence to support a conclusion concerning the
health outcomes or benefits associated with this procedure.
IV.
EXCLUSIONS
N/A
V.
BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
VI.
DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute
medical advice and are subject to change. Treating providers are solely responsible for medical advice and
treatment of members. Members should discuss any medical policy related to their coverage or condition
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL
POLICY
POLICY TITLE
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR
INTRACRANIAL STENOSIS WITH OR WITHOUT STENTING
POLICY NUMBER
MP-1.089
with their provider and consult their benefit information to determine if the service is covered. If there is a
discrepancy between this medical policy and a member’s benefit information, the benefit information will
govern. Capital considers the information contained in this medical policy to be proprietary and it may only
be disseminated as permitted by law.
VI.
REFERENCES
Alazzaz A, Thornton J, Aletich VA et al. Intracranial percutaneous transluminal
angioplasty for arteriosclerotic stenosis. Arch Neurol 2000; 57(11): 1625-30.
Gress DR, Smith WS, Dowd CF et al. Angioplasty for intracranial symptomatic
vertebrobasilar ischemia. Neurosurgery 2002; 51(1): 23-9.
Jenkins JS, White CJ, Ramee SR et al. Vertebral artery stenting. Catheter Cardiovasc
Interv 2001; 54(1): 1-5.
Levy EI, Horowitz MB, Koebbe CJ et al. Transluminal stent-assisted angioplasty of the
intracranial vertebrobasilar system for medically refractory, posterior circulation
ischemia: early results. Neurosurgery 2001; 48(6): 1215-23.
Nahser HC, Henkes H, Weber W et al. Intracranial vertebrobasilar stenosis: angioplasty
and follow-up. AJNR Am J Neuroradiol 2000; 21(7): 1293-301.
Taber’s Cyclopedic Medical Dictionary, 19th edition
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
VIII. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] CHIP PPO
[N] Indemnity
[N] PPO
[N] SpecialCare
[N] HMO
[N] POS
[N] CHIP HMO
[N] FEP HMO
[N] SeniorBlue
[N] Medicare PPO
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[Note: Final page is signature page and is kept on file, but not issued with Policy.]
MEDICAL
POLICY
POLICY TITLE
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY FOR
INTRACRANIAL STENOSIS WITH OR WITHOUT STENTING
POLICY NUMBER
MP-1.089
IX.
POLICY HISTORY
Policy approved for retirement effective 10/24/2005.
See Policy 2.032.
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