Description
Computed tomography angiography (CTA) provides a cost-effective and accurate imaging assessment in patients with aortic dissections or peripheral arterial disease. High resolution CTA may be used in the diagnosis and follow-up of patients with aortic dissection and lower extremity peripheral arterial disease (PAD).

OVERVIEW:
Suspected Peripheral Arterial Disease — CTA (or MRA) is an excellent tool to diagnose lower extremity peripheral arterial disease (PAD). Benefits include the fast scanning time and accurate detection of occlusions and stenosis. According to the Society for Vascular Surgery guidelines, "Measurement of the ankle-brachial index (ABI) is the primary method for establishing the diagnosis of PAD. An ABI of ≤ 0.90 has been demonstrated to have high sensitivity and specificity for the identification of PAD compared with the gold standard of invasive arteriography. The presence of a normal ABI at rest and following exercise almost excludes atherosclerotic disease as a cause for leg claudication.

"When an ABI is > 1.40 and clinical suspicion is high, other tests, such as toe-brachial index < 8, a resting toe pressure < 40 mmHg, a systolic peak posterior tibial artery flow velocity < 10 cm/s may be used. In symptomatic patients in whom revascularization treatment is being considered, we recommend anatomic imaging studies, such as arterial duplex ultrasound, CTA, MRA, and contrast arteriography." This statement is accompanied by a "B" (moderate) rating for the accompanying evidence ("A" = high, "C" = low): "In patients with limited renal function or planned surgical intervention, noninvasive imaging tests (particularly MRA and CTA) may obviate the need for diagnostic catheter angiography to visualize the location and severity of peripheral vascular disease."

Follow-up imaging after vascular surgery procedures has not been well researched without clear surveillance protocols in place. Clinical exam, ABI and EUS within the first month of endovascular therapy generally recommended to assess for residual stenosis and again at 6 and 12 months, then annually. More sophisticated imaging with CTA or MRA, or invasive catheter angiography, is reserved for complex cases.

IMPORTANT NOTE: 

Only one authorization request is required, using CPT Code 75635 Abdominal Arteries CTA with runoff. This study provides for imaging of the abdomen, pelvis, and both legs and is the noninvasive equivalent to an "aortogram and runoff."

Policy:
ABDOMINAL ARTERIES CTA with runoff is considered MEDICALLY NECESSARY for the following indications:

For evaluation of vascular abnormality seen on previous imaging in the abdominal aorta and/or legs

For evaluation of known or suspected abdominal, pelvic, or peripheral vascular disease:

• Without critical ischemic changes doppler ultrasound should be indeterminate or inconclusive
• For known or suspected peripheral arterial disease when non-invasive studies (pulse volume recording, ankle-brachial index, or ultrasound) are abnormal or equivocal.
• For Critical limb ischemia with ANY of the below clinical signs of peripheral artery disease. Ultrasound imaging is not needed. If done and negative, it should still be approved due to a high false negative rate 
  • • Ischemic rest pain
    • Tissue loss
    • Gangrene
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound (ankle/brachial index, arterial Doppler)

Pre-operative evaluation:

• Evaluation of interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia

Post-operative or post-procedural evaluation:

• Evaluation of post-operative complications, e.g., pseudoaneurysms related to surgical bypass grafts, vascular stents and stent-grafts.
• Follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.  
• After stenting or surgery with signs of recurrent symptoms OR abnormal ankle/brachial index; abnormal or indeterminate arterial doppler; OR pulse volume recording

All other uses of this technology are investigational and/or unproven and therefore considered NOT MEDICALLY NECESSARY. 

References 

1. Ahmed O, Hanley M, Bennett SJ, et al. ACR Appropriateness Criteria^® - Vascular Claudication – Assessment for Revascularization. J Am Coll Radiol. 2017 May; 14(5S):S372-379.
2. American College of Radiology (ACR). ACR Appropriateness Criteria^®. https://acsearch.acr.org/list. Revised 2016.
3. Bailey SR, Beckman JA, Dao, TD, et al. ACC / AHA / SCAI / SIR / SVM 2018 Appropriate Use Criteria for Peripheral Artery Intervention: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine. J Am Coll Cardiol. 2018.
4. Barnes, GD. Society of Vascular Surgery Guidelines for Peripheral Artery Disease Management/ Ten Points to Remember. J Vasc Surg; 2015; 61.
5. Conte M, Pomposelli, FB, Clair DG, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication. J Vasc Surg. March 2015; 61(3):2S–41S.e1. https://doi.org/10.1016/j.jvs.2014.12.009. http://www.jvascsurg.org/article/S0741-5214%2814%2902284-8/fulltext. Retrieved February 15, 2018.
6. Duan, Y., Wang, X, .et. al. Diagnostic Efficiency of Low-Dose CT Angiography compared with Conventional Angiography in Peripheral Arterial Occlusions. AJR. 2013; 201(6).
7. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral arterial disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Mar 21; 69(11):1465-1508.
8. Hodnett PA, Koktzoglou I, Davarpanah AH, et al. Evaluation of peripheral arterial disease with nonenhanced quiescent-interval single-shot MR angiography. Radiology. 2011; 260: 282-293. doi: 10.1148/radiol.11101336.
9. Lin PH, Bechara C, Kouglas P, et al. Assessment of aortic pathology and peripheral arterial disease using multidetector computed tomographic angiography. Vasc Endovascular Surg. 2009; 42(6):583-598. doi: 10.1177/1538574408320029.
10. Met R, Bipat MR, Legemate DA, et al. Diagnostic performance of computed tomography angiography in peripheral arterial disease: A systematic review and meta-analysis. JAMA. 2009; 301(4):415-424. doi:10.1001/jama.301.4.415.  
11. Rosyd, FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017; 5(10):4206-4213.
12. Stoner MC, Calligaro KD, Chaer RA, et al. Reporting standards of the Society for Vascular Surgery for endovascular treatment of chronic lower extremity peripheral artery disease. J Vasc Surg. 2016 Jul; 64(1):e1-21.
13. Weiss, C., Azene, ER,. et. al. Sudden Onset of Cold, Painful foot. J Am Coll Radio. 2017; 14(5).
14. Werncke, T, Ringe, KI, et. al. Diagnostic Confidence of Run-Off CT-Angiography as the Primary Diagnostic Imaging Modality in Patients Presenting with Acute or Chronic Peripheral Arterial Disease. PLoS One. 2015;: 10(4).
15. Zierler, RE., Jordan, WD,. et. al. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J. Vasc. Surg. 2018; 68:256-284.

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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