Description
Computed tomographic angiography (CTA) is used in the evaluation of many conditions affecting the veins and arteries of the pelvis or lower extremities. It is not appropriate as a screening tool for asymptomatic patients without a previous diagnosis.

OVERVIEW
CT/MRI and acute hemorrhage: MRI is not indicated and MRA/MRV (MR angiography/venography) is rarely indicated for evaluation of intraperitoneal or retroperitoneal hemorrhage, particularly in the acute setting. CT is the study of choice due to its availability, speed of the study and less susceptibility to artifact from patient motion. Advances in technology have allowed conventional CT to not just detect hematomas but also the source of acute vascular extravasation. In special cases, finer vascular detail to assess the specific source vessel responsible for hemorrhage may require the use of CTA. CTA in diagnosis of lower gastrointestinal bleeding is such an example.

Follow-up of asymptomatic, incidentally-detected iliac artery aneurysms: The definition of an iliac artery aneurysm (IAA) is dilitation to more than 1.5 times its normal diameter; in general a common iliac artery ≥ 18 mm in men and ≥ 15 mm in women; an internal iliac argery (IIA) > 8 mm is considered aneurysmal. There are four types of isolated iliac aneurysms classified by Reber. Suggested surveillance is extrapolated from AAA surveillance and can be done by Doppler ultrasound or CTA if hard to visualize by ultrasound.

Policy
INDICATIONS FOR PELVIS CT Angiography / CT Venography (CTA/CTV): When both the abdomen and pelvis are involved (or suspected to be), should be ordered as Abdomen/Pelvis CTA (CPT Code: 74174).

For evaluation of known or suspected vascular disease¹

• For pelvic extent of known large vessel diseases (abdominal aorta, inferior vena cava, superior/inferior mesenteric, celiac, splenic, renal or iliac arteries/veins), e.g., aneurysm, dissection, arteriovenous malformations (AVMs), fistulas, intramural hematoma and vasculitis
• Evidence of vascular abnormality seen on prior imaging studies
• For suspected pelvic extent of aortic dissection
• Evaluation of known or suspected aneurysms limited to the pelvis or in evaluating pelvic extent of aortic aneurysm^2,3,4
  • Known or suspected iliac artery aneurysm AND equivocal or indeterminate Doppler ultrasound results
  • If repeat Doppler ultrasound is indeterminate
  • Suspected complications of known aneurysm as evidenced by clinical findings such as new onset of pelvic pain
• Follow-up of iliac artery aneurysm:
  • Every three years for diameter 2.0 – 2.9 cm
  • Annually for 3.0 – 3.4 cm if Doppler ultrasound is inconclusive
  • If > 3.5 cm, < 6-month follow-up (and consider intervention)⁴
• Suspected retroperitoneal hematoma or hemorrhage: to determine vascular source of hemorrhage, in setting of trauma, tumor invasion, fistula or vasculitis, otherwise CT/MR abdomen and pelvis (rather than CTA/MRA) may be sufficient and the modality of choice for diagnosing hemorrhage⁵
• For evaluation of suspected pelvic vascular disease or pelvic congestive syndrome when findings on ultrasound are indeterminate (MR or CT venography may be used as the initial study for pelvic thrombosis or thrombophlebitis)^6,7
• For evaluation of venous thrombosis in the inferior vena cava⁸
• National Imaging Associates Inc. (NIA) is a subsidiary of Magellan Healthcare Inc.
• Venous thrombosis if previous studies have not resulted in a clear diagnosis⁹
• Vascular invasion or displacement by tumor (conventional CT or MRI also appropriate)^10,11
• For evaluation of suspected mesenteric ischemia/ischemic colitis (can approve CTA/MRA abdomen and pelvis)¹²

Other vascular indications

• For suspected May-Thurner Syndrome (iliac vein compression syndrome) (can include abdomen CTA)^13,14
• Lower gastrointestinal hemorrhage: Active bleeding in a hemodynamically stable patient or non-localized intermittent bleeding as an alternative to Tc-99m RBC scan when colonoscopy did not localize the bleeding, is contraindicated, or unavailable^15,16
• For evaluation of erectile dysfunction when a vascular cause is suspected and Doppler ultrasound is inconclusive¹⁷
• For patients with fibromuscular dysplasia (FMD), a one-time vascular study of the abdomen and pelvis¹⁸ so should be abdomen/pelvis CTA (CPT 74174)
• For patients with vascular Ehlers-Danlos syndrome or Marfan syndrome recommend a one-time vascular study of the abdomen and pelvis so should be abdomen/pelvis CTA (CPT 74174)
• For Loeys-Dietz vascular imaging every two years (include abdomen CTA)¹⁹
• For spontaneous coronary artery dissection (SCAT) at time of coronary arteriography (includes CTA abdomen)²⁰ so should be abdomen/pelvis CTA (CPT 74174)

Pre-operative evaluation^{21, 22}

• Evaluation of interventional vascular procedures prior to endovascular aneurysm repair (EVAR), or for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia
• Imaging of the deep inferior epigastric arteries for surgical planning (breast reconstruction surgery) include abdomen CTA/MRA²²
• Prior to uterine artery embolization for fibroids (MRA preferred)²³

Post-operative or post-procedural evaluation

• Evaluation of post-operative complications of renal transplant allograft²⁴
• Evaluation of endovascular/interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism and intimal hyperplasia
• Evaluation of post-operative complications, e.g., pseudoaneurysms related to surgical bypass grafts, vascular stents and stent-grafts in the pelvis
• Follow-up for post-endovascular repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) and iliac artery aneurysms typically needs to include abdominal imaging, therefore abdomen/pelvis CTA would usually be the appropriate study

Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA combo

• For evaluation of extensive vascular disease involving the chest and abdominal cavities
• For preoperative or preprocedural evaluation, such as TAVR (transcatheter aortic valve replacement) or transcatheter venous ablation^21,25
• Acute aortic dissection²⁶
• Takayasu’s arteritis²⁷
• Marfan syndrome
• Loeys-Dietz syndrome
• Spontaneous coronary artery dissection (SCAD)
• Vascular Ehlers-Danlos syndrome
• Post-operative complications^28,29
• Significant post-traumatic or post-procedural vascular complications

IMPORTANT NOTE: When encountering requests for abdomen/pelvis CTA and lower extremity CTA (Runoff) requests, these should be abdominal arteries CTA. Only one authorization request is required, using CPT Code 75635. This study provides for imaging of the abdomen, pelvis and both legs and is the noninvasive equivalent to an “aortogram and run-off."

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

References 

1. Abe T, Kai M, Miyoshi O, et al. Idiopathic retroperitoneal hematoma. Case Rep Gastroenterol. September-December 2010; 4(3):318-322. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974992/. Retrieved February 12, 2018.
2. Al-Nouri O, Milner R. May-Thurner Syndrome. Clin Rev. 2011; 8(3). https://www.vasculardiseasemanagement.com/content/may-thurner-syndrome. Accessed May 9, 2019.
3. American College of Radiology (ACR). ACR Appropriateness Criteria®. https://acsearch.acr.org/list. Published 2018.
4. Aw-Zoretic J, Collins JD. Considerations for imaging the inferior vena cava (IVC) with/without IVC Filters. Semin Intervent Radiol. 2016; 33(2):109-21.
5. Barman M. Acute aortic dissection. Euro Society Cardiol. 2014; 12(25).
6. Bennet KM, Kent KC, Schumacher J, et al. Targeting the most important complications in vascular surgery. J Vasc Surg. 2017; 65(3):793-803.
7. Bookwalter, CA., Van Buren, WM,. et. al. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. Radiographics. 2019; 39(2).
8. Bultman EM, Klaers J, Johnson KM, et al. Non-contrast enhanced 3D SSFP MRA of the renal allograft vasculature: A comparison between radial linear combination and cartesian inflow-weighted acquisitions. Magn Reson Imaging. 2014; 32(2):190–195.
9. Certik B, Treska V, Molacek J, et al. Cardiovascular Surgery. How to proceed in the case of a tumor thrombus in the inferior vena cava with renal cell carcinoma. Cor et Vasa. April 2015; 57(2):e95-e100. https://www.sciencedirect.com/science/article/pii/S0010865015000260. Retrieved February 12, 2018.
10. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. January 2018; 67(1):2- 77.e2. http://www.jvascsurg.org/article/S0741-5214(17)32369-8/fulltext#sec1.3. Retrieved February 15, 2018.
11. Choudhury, M. Postoperative Management of Vascular Surgery Patients: A Brief Review. Clin Surg. 2017; 2:1584.
12. Chu, LC., Johnson, PT., Dietz HC, et. al. CT Angiographic Evaluation of Genetic Vascular Disease: Role in Detection, Staging, and Management of Complex Vascular Pathologic Conditions. AJR Am J Roentgenol. 2014 May; 202(5):1120-9.
13. Clerc D, Grass F, Schafer M, et al. Lower gastrointestinal bleeding—Computed tomographic angiography, colonoscopy or both? World J Emerg Surg. 2017; 12:1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215140/. Retrieved February 12, 2018.
14. Crousillat, DR., Wood, MJ., et. al. Spontaneous Coronary Artery Dissection: An Update for the Interventionalist. Cath Lab Digest. March; 2020:28(3).
15. Eren S. Multi-detector row computed tomography findings of pelvic congestion syndrome caused by dilated ovarian veins. Eurasian J Med. 2010 Dec; 42(3):128-31.
16. Henes FO, Pickhardt PJ, Herzyk A, et al. CT angiography in the setting of suspected acute mesenteric ischemia: prevalence of ischemic and alternative diagnoses. Abdom Radiol (NY). 2017 Apr; 42(4):1152-1161. doi: 10.1007/s00261-016-0988-0.
17. Kadian-Dodov, D., Gornik, HL,. et. al. Diissection and Aneurysm in Patients w ith Fibromuscular Dysplasia: Findings from the US Registry for FMD. Journal of the Am Coll of Cardiology. 2016; 68(2).
18. Kalu S, Shah P, Natarajan A, et al. May-thurner syndrome: A case report and review of the literature. Case Rep Vasc Med. 2013; 2013:740182. Epub 2013 Feb 20.
19. Keser G, Direskeneli H, Aksu K, et al. Management of Takayasu Arteritis: A systematic review. Rheumatology. 2014; 53(5):793-801.
20. Khalil H, Avruch L, Olivier A, et al. The natural history of pelvic vein thrombosis on magnetic resonance venography after vaginal delivery. Am J Obstet Gynecol. 2012; 206(4):356.
21. Khosa F, Krinsky G, Macari M, et al. Managing incidental findings on abdominal and pelvic CT and MRI, Part 2: White paper of the ACR Incidental Findings Committee II on vascular findings. J Am Coll Radiol. 2013; 10(10):789-794. doi:10.1016/j.jacr.2013.05.021.
22. Knuttinen, M-G., Xie, K., et. al. Pelvic Venous Insufficiency: Imaging, Diagnosis, Treatment Approaches and Therapeutic Issues. AJR. 2015; 204(2).
23. Liu PS, Platt JF. CT angiography of the renal circulation. Radiol Clin North Am. 2010; 48(2):347-365. doi: 10.1016/j.rcl.2010.02.005.
24. Maciel, C., Tang, YZ, et. al. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017; 23(2): 163-171.
25. Ohana M, Bakouboula B, Labani A, et al. Imaging before and after catheter ablation of atrial fibrillation. Diagn Interv Imaging. 2015 Nov; 96(11):1113-23.
26. Seitz M, Waggershauser T, Khoder W. Congenital intrarenal arteriovenous malformation presenting with gross hematuria after endoscopic intervention: A case report. J Med Case Rep. 2008; 2:326. doi: 10.1186/1752-1947-2-326.
27. Shindel AW, Brandt WO, Bochinski D, et al. Medical and Surgical Therapy of Erectile Dysfunction. In: Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. 2018 Jul 10. https://www.ncbi.nim.nih.gov/books. July 10, 2018.
28. Smillie R, Shetty M, Boyer AC, et al. Imaging Evaluation of the inferior vena cava. RadioGraphics. 2015; 35(2). https://pubs.rsna.org/doi/full/10.1148/rg.352140136.
29. Sommer WH, Becker CR, Haack M, et al. Time-resolved CT Angiography for the Detection and Classification of Endoleaks. Radiol. 2012; 263(3):917-26. https://pubs.rsna.org/doi/full/10.1148/radiol.12111217.
30. Thakur V, Inampudi P, Pena CS. Imaging of mesenteric ischemia. Applied Radiology. 2018; 47(2):13-18.
31. Uberoi R, Tsetis D, Shrivastava V, et al. Standard of practice for the interventional management of isolated iliac artery aneurysms. Cardiovasc Intervent Radiol. 2011; 34(1):3-13. doi:10.1007/s00270-010-0055-0.
32. Wanhainen A, Verzini F, Van Herzeele I, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57(1):8-93.

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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