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61630 (Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous), 61635 Transcatheter placement of intravascular stent(s), intracranial, including balloon angioplastyInformation below was retrieved from the March 2016 VbBS materials. Minutes indicate approval of the staff recommendation with minimal discussion.Issue: When reviewing similar codes (intra-arterial mechanical thrombectomy) for a previous VbBS meeting, HERC staff discovered similar procedures that were currently being covered but which appeared to have limited evidence of effectiveness. Staff Recommendation: Place 61630 on SRNC because there is no evidence of effectiveness and there is evidence of harm. Intracranial balloon angioplasty appears to be much less studied than intracranial vascular stenting, but has similar or worse outcomes than stenting in the studies identified. Affirm placement of 61635 on SRNC.Evidence: NICE 2012 Endovascular stent insertion for intracranial atherosclerotic disease: No substantial differences in outcomes compared with medical treatment but significant risk of periprocedural stroke and death. Only should be used in context of research. VISSIT RCT of balloon angioplasty/stent vs medical management for intracranial stenosis: Zaidat 2015 - Findings did not support the use of a balloon-expandable stent for patients with symptomatic intracranial arterial stenosis. SAMMPRIS RCT of stenting vs aggressive medical management for acute stroke and intracranial artery stenosis:Chimowitz 2011 RCT early outcomes - Aggressive medical management was superior to stenting. Derdeyn 2014 RCT later outcomes - Aggressive medical management was superior to stenting with the Wingspan system in high-risk patients with atherosclerotic intracranial arterial stenosis. Teleb 2014 review of endovascular management for intracranial atherosclerotic disease: Very high complication ratesCruz-Flores 2008 Cochrane review of angioplasty for intracranial atherosclerosis: Insufficient evidence to recommend angioplasty with or without stent placement in routine practice for prevention of stroke in pts with intracranial artery stenosis. Descriptive studies show that procedure is feasible but has high morbidity and mortality risk. Guidelines:Jauch 2013 AHA/ASA guidelines for the treatment of acute stroke: The usefulness of emergent intracranial angioplasty and/or stenting is not well established. These procedures should be used in the setting of clinical trials (Class IIb; Level of Evidence C.) ................
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