Description
Magnetic resonance angiography (MRA) generates images of the arteries that can be evaluated for evidence of stenosis, occlusion, or aneurysms. It is used to evaluate the arteries of the abdominal aorta and the renal arteries. Contrast enhanced MRA requires the injection of a contrast agent which results in very high quality images. It does not use ionizing radiation, allowing MRA to be used for follow-up evaluations.

OVERVIEW:
Bruits: Blowing vascular sounds heard over partially occluded blood vessels. Abdominal bruits may indicate partial obstruction of the aorta or other major arteries such as the renal, iliac, or femoral arteries. Associated risks include but are not limited to; renal artery stenosis, aortic aneurysm, atherosclerosis, AVM, or coarctation of aorta.

MRA and Chronic Mesenteric Ischemia: Contrast-enhanced MRA is used for the evaluation of chronic mesenteric ischemia, including treatment follow-up. Chronic mesenteric ischemia is usually caused by severe atherosclerotic disease of the mesenteric arteries, e.g., celiac axis, superior mesenteric artery, inferior mesenteric artery. At least two of the arteries are usually affected before the occurrence of symptoms such as abdominal pain after meals and weight loss. MRA is the technique of choice for the evaluation of chronic mesenteric ischemia in patients with impaired renal function.

MRA and Abdominal Aortic Aneurysm Repair: MRA may be performed before endovascular repair of an abdominal aortic aneurysm. Endovascular repair of abdominal aortic aneurysm is a minimally invasive alternative to open surgical repair and its success depends on precise measurement of the dimensions of the aneurysm and vessels. This helps to determine selection of an appropriate stent-graft diameter and length to minimize complications such as endoleakage. MRA provides images of the aorta and branches in multiple 3D projections and may help to determine the dimensions needed for placement of an endovascular aortic stent graft. MRA is noninvasive and rapid and may be used in patients with renal impairment.

MRI/CT 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 the diagnosis of lower gastrointestinal bleeding is such an example (Clerc, 2017).

MRA/MRV is often utilized in non-acute situations to assess vascular structure involved in atherosclerotic disease and its complications, vasculitis, venous thrombosis, vascular congestion or tumor invasion. Although some of these conditions may be associated with hemorrhage, it is usually not the primary reason why MRI/MRA/MRV is selected for the evaluation. A special condition where MRI may be superior to CT for evaluating hemorrhage is to detect an underlying neoplasm as the cause of bleeding (Abe, 2010).

Policy  
IMPORTANT NOTE:
Abdomen/Pelvis Magnetic Resonance Angiography (MRA) & Lower Extremity MRA Runoff Requests: Two authorization requests are required, one Abdomen MRA, CPT code 74185 and one for Lower Extremity MRA, CPT code 73725 (a separate Pelvic MRA request is not required). This will provide imaging of the abdomen, pelvis, and both legs.

INDICATIONS FOR PELVIS MR Angiography / MR Venography (MRA/MRV)

Arterial

Evaluation of known or suspected pelvic vascular disease.

• Evidence of vascular abnormality seen on prior imaging studies
• 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
• For suspected pelvic extent of aortic dissection (approve CTA/MRA abdomen and pelvis)
• For evaluation of known or suspected aneurysms limited to the pelvis or evaluating pelvic extent of aortic aneurysm ^1,2,3
  • Known or suspected iliac artery aneurysm AND equivocal or indeterminate Doppler ultrasound results and contraindication to CTA
  • 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 if between 3.0 – 3.4 if Doppler ultrasound is inconclusive
  • If > 3.5 cm, < six month follow-up (and consider intervention)³
• To determine a vascular source of retroperitoneal hematoma or hemorrhage in the setting of trauma, tumor invasion, fistula or vasculitis when CTA is contraindicated (CT rather than MRA/CTA is the modality of choice for diagnosing hemorrhage⁴)
• For known or suspected mesenteric ischemia/ischemic colitis when CTA is contraindicated (can approve MRA abdomen and pelvis)⁵
• Vascular invasion or displacement by tumor (Conventional CT or MRI also appropriate)⁶
• For patients with fibromuscular dysplasia (FMD), a one-time vascular study of the abdomen and pelvis (CTA or MRA)⁷
• For patients with Vascular Ehlers-Danlos syndrome or Marfan syndrome recommend a one- time study of the abdomen and pelvis (CTA/MRA)
• For Loeys-Dietz imaging at least every two years⁸
• For assessment in patients with spontaneous coronary artery dissection (SCAD) can be done at time of coronary angiography (also approve CTA pelvis)⁹
   

Venous

• For evaluation of suspected pelvic vascular disease or pelvic congestive syndrome when findings on ultrasound are indeterminate (MR or CT venography (CTV) may be used as the initial study for evaluating pelvic thrombosis or thrombophlebitis)^10,11
• For diffuse, unexplained lower extremity edema with negative or inconclusive ultrasound¹²
• For evaluation of venous thrombus in the inferior vena cava¹³
• Venous thrombosis if previous studies have not resulted in a clear diagnosis¹⁴
• Vascular invasion or displacement by tumor (Conventional CT or MRI also appropriate)⁶
• For known/suspected May-Thurner Syndrome (iliac vein compression syndrome)^15,16

Pre-operative evaluation^17,18,19

• Evaluation prior to interventional vascular for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia
• Evaluation prior to endovascular aneurysm repair (EVAR)
• Imaging of the deep inferior epigastric arteries for surgical planning (breast reconstruction surgery) include CTA/MRA abdomen¹⁸
• Prior to uterine artery embolization for fibroids²⁰

Post-operative or post-procedural evaluation

• Post-operative complications of renal transplant allograft²¹
• Endovascular/ interventional vascular procedures for luminal patency versus restenosis due to conditions such as atherosclerosis, thromboembolism, and intimal hyperplasia
• 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
  • Routine, baseline study (post-op/intervention) is warranted within 1 – 3 months^2,22 (abdomen and pelvis MRA when CTA is inconclusive or cannot be performed)
  • Asymptomatic at six month intervals, for one year, then annually
  • Symptomatic/complications related to stent graft — more frequent imaging may be needed
• 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.
   

Chest MRA, Abdomen MRA, or Abdomen/Pelvis MRA combo

• Acute aortic dissection (CTA or CT preferred)
• Takayasu’s arteritis
• Marfan sydrome
• Loeys-Dietz syndrome
• Spontaneous coronary artery dissection (SCAD)
• Vascular Ehlers-Danlos syndrome
• Post-operative complications
• Significant post-traumatic or post-procedural vascular complications reasonably expected to involve the chest and/or abdomen and/or pelvis
   

References 

1. Abe T, Kai M, Miyoshi O, et al. Idiopathic retroperitoneal hematoma. Case Rep Gastroenterol. September-December 2010; 4(3):318-322. Retrieved 2/12/18 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974992/. Retrieved February 12, 2018.
2. Al-Nouri O, Milner R. May-Thurner Syndrome. Clinical Review. 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 2013.
4. American College of Radiology (ACR). ACR Appropriateness Criteria. https://acsearch.acr.org/list. Published 2018.
5. 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.
6. Baradhi K, Bream P. Fibro muscular Dysplasia. Stat Pearls (Internet). December 18, 2019.
7. Bookwater CA, Van Buren WM, et al. Imaging Appearance and Nonsurgical Management of Pelvic Venous Congestion Syndrome. Radiographics. 2019; 319(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. Chu LC, Johnson PT, 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; 202(5).  
12. Clerc D, Grass F, Schafer M, et al. Lower gastrointestinal bleeding—Computed tomographic angiography, colonoscopy or both? World J Emerg Surg. 2017; 12:1. Retrieved February 12, 2018.
13. Cohen EI, Weinreb DB, Siegelbaum RH, et al. Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair. J Magn Reson Imaging. 2008; 27(3):500-503. doi: 10.1002/jmri.21257.
14. Hoshino Y, Hoshino, Machida M, Shimano S, et al. Unilateral Leg Swelling: Differential Diagnostic Issue Other than Deep Vein Thrombosis. J Gen Fam Med. 2016; 17:311-314. 10.14442/jgfm.17.4_311.
15. Jesinger RA, Thoreson AA, Lamba R. Abdominal and pelvic aneurysms and pseudoaneurysms: Imaging review with clinical, radiologic, and treatment correlation. RadioGraphics. 2013; 33(3):E71-96. doi: 10.1148/rg.333115036.
16. Kadian-Dodov D, Gornik HL, et al. Dissection and Aneurysm in Patients with Fiibromuscular Dysplasia: Findings from the US Registry for FMD. J Am. Coll Cardiol. 2016; 68(2).  
17. 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.
18. 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.
19. 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.
20. Knuttinen M-G, Xie K, et al. Pelvic Venous Insufficiency Imaging: Diagnosis, Treatment Approaches and Therapeutic Issues. AJR. 2015; 204(2).  
21. Maciel, C., Tang, YZ., et. al. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017; 23(2):163-171.  
22. Soulez G, Pasowicz M, Benea G, et al. Renal artery stenosis evaluation: Diagnostic performance of gadobenate dimeglumine-enhanced MR angiography--comparison with DSA. Radiology. 2008; 247(1):273-285. http://radiology.rsna.org/content/247/1/273.full.pdf+html.
23. Maciel, C., Tang, YZ.,et.al. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol 2017;23(2):163-171
24. Textor SC, Lerman L. Renovascular hypertension and ischemic nephropathy. Am J Hypertens. 2010; 23(11):1159-1169. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3078640/. 
25. Thakur V, Inampudi P, Pena CS. Imaging of mesenteric ischemia. Applied Radiology. 2018; 47(2):13-18.
26. 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.
27. 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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