Medical Necessity of Transcatheter Placement of Intravascular Stent in Acute Stroke

Primary Justification for Medical Necessity

The American Heart Association/American Stroke Association (AHA/ASA) guidelines support angioplasty and stenting of proximal cervical atherosclerotic stenosis or complete occlusion at the time of thrombectomy (Class IIb; Level of Evidence C), particularly when performed within 6 hours of symptom onset, for patients with acute symptomatic presentation, tandem occlusion, and emergent intervention 2
The AHA/ASA guidelines recommend intervention for patients with acute symptomatic left ICA occlusion presenting within the thrombectomy time window, despite the complete occlusion noted on imaging, with a strength of evidence of Class IIb 1, 2
Patients with acute symptomatic presentation, tandem occlusion involving both cervical ICA origin and M2 branch, and emergent intervention performed within the therapeutic window, are likely to benefit from transcatheter placement of intravascular stent, as evidenced by the AHA/ASA guidelines 1, 2

The AHA/ASA guidelines distinguish between chronic total occlusion (contraindicated for revascularization) and acute occlusion (indicated for intervention), with the critical distinction being the timing of occlusion, as stated in the guidelines 2, 3 (not from 'Praxis Medical Insights')
The American College of Cardiology (ACC) guidelines state that carotid revascularization is not recommended for patients with chronic total occlusion, but this does not apply to acute thrombotic events precipitating stroke 4

The AHA/ASA guidelines acknowledge that patients with carotid stenosis or occlusion in the MR CLEAN intervention arm were stented during thrombectomy, with a proportion of 40%, and 9 of 19 patients with carotid occlusion in REVASCAT received stents 1

The technical goal of achieving TICI 2b/3 recanalization (Class I; Level of Evidence A) often requires addressing the proximal cervical lesion in tandem occlusions, as recommended by the AHA/ASA guidelines 2
The AHA/ASA guidelines support the use of transcatheter placement of intravascular stent for patients with acute symptomatic tandem occlusion, with a strength of evidence of Class I 1, 2