GENERAL INFORMATION

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy 
When a separate CTA and CT exam is requested, documentation requires a medical reason that clearly indicates why additional CT imaging of the upper extremity is needed.

INDICATIONS FOR UPPER EXTREMITY CTA/CTV (Computed Tomography Angiogram/Computed Tomography Venogram)

Hand Ischemia^1,2

• Arterial Doppler not needed with any of these acute symptoms:
  • Ischemic ulceration without segmental temperature change
  • Ischemic ulceration with painful ischemia
  • Acute sustained loss of perfusion with or without acral ulceration
  • Imminent loss of digit
• Clinical symptoms without the above features; with abnormal arterial Doppler and will change management
  • Includes Raynaud’s (can be associated with scleroderma), Buerger disease, and other vasculopathies³
• Clinical concern for vascular cause of ulcers with abnormal or indeterminate ultrasound⁴
• After stenting or surgery with signs of recurrence or indeterminate ultrasound⁵

Deep Venous Thrombosis or Embolism

• After abnormal ultrasound of arm veins if it will change management, or with negative or indeterminate ultrasound to rule out other causes
• For evaluation of central veins 
• Clinical suspicion of upper arterial emboli^8,9

Clinical suspicion of vascular disease with abnormal or indeterminate ultrasound^8,9

• Tumor invasion^10,11
• Trauma¹²
• Vasculitis^1,13
• Aneurysm¹⁴
• Stenosis/occlusions^{15, 16}

Hemodialysis Graft Dysfunction, after Doppler ultrasound not adequate for treatment decisions¹⁷

Vascular Malformation

• After initial evaluation with ultrasound and results will change management OR
• Inconclusive ultrasound OR
• If a known or suspected high flow lesion
• For preoperative planning (CT is also approvable for initial evaluation if MRI contraindicated)

(MRA preferred however CTA useful in delineating some high flow lesions such as an arteriovenous malformation)

Traumatic injuries with clinical findings suggestive of arterial injury¹²

Assessment/evaluation of known vascular disease/condition

Further evaluation of indeterminate findings on prior imaging (unless follow-up is otherwise specified within the guideline):

• For initial evaluation of an inconclusive finding on a prior imaging report (i.e., X-ray, ultrasound or CT) that requires further clarification.
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly  suspicious or change was found on last follow-up exam.)

Pre-operative/procedural evaluation

• Pre-operative evaluation for a planned surgery or procedure²⁰

Post-operative/procedural evaluation

• A 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.^21,22

Special Circumstances²³

• High suspicion of an acute arterial obstruction - Arteriography preferred (the gold standard)
• Renal impairment 
  • Not on dialysis
    • Mild to moderate, GFR 30 – 45 ml/min MRA with contrast can be performed
    • Severe, GFR < 30 ml/min MRA without contrast 
  • On dialysis 
    • CTA with contrast can be performed
• Doppler ultrasound can be useful in evaluating bypass grafts

Rationale
Computed tomography angiography (CTA) can visualize blood flow in arterial and venous structures throughout the upper extremity using a computerized analysis of x-ray images. It is enhanced by contrast material that is injected into a peripheral vein to promote visualization. CTA is much less invasive than catheter angiography which involves injecting contrast material into an artery. CTA is less expensive and carries lower risks than catheter angiography.

OVERVIEW
UPPER EXTREMITY DVT — “Secondary UEDVT is far more common. Indwelling venous devices, such as catheters, pacemakers, and defibrillators, put patients at the highest risk of thrombus. Other risk factors include advanced age, previous thrombophlebitis, postoperative state, hypercoagulability, heart failure, cancer, right-heart procedures, intensive care unit admissions, trauma, and extrinsic compression.”⁶

CTA and Dialysis Graft — The management of the hemodialysis access is important for patients undergoing dialysis. With evaluation and interventions, the patency of hemodialysis fistulas may be prolonged. In selected cases, CTA is useful in the evaluation of hemodialysis graft dysfunction due to its speed and high resolution. Rapid data acquisition during the arterial phase, improved visualization of small vessels and lengthened anatomic coverage increase the usefulness of CTA. 

References

1. Hotchkiss R, Marks T. Management of acute and chronic vascular conditions of the hand. Curr Rev Musculoskelet Med. Mar 2014;7(1):47-52. doi:10.1007/s12178-014-9202-6
2. Wong VW, Major MR, Higgins JP. Nonoperative Management of Acute Upper Limb Ischemia. Hand (N Y). Jun 2016;11(2):131-43. doi:10.1177/1558944716628499
3. McMahan ZH, Wigley FM. Raynaud's phenomenon and digital ischemia: a practical approach to risk stratification, diagnosis and management. Int J Clin Rheumtol. 2010;5(3):355-370. doi:10.2217/ijr.10.17
4. Rosyid FN. Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci. 2017;5(10):4206-13. doi:http://dx.doi.org/10.18203/2320-6012.ijrms20174548
5. Pollak AW, Norton PT, Kramer CM. Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging. Nov 2012;5(6):797-807. doi:10.1161/circimaging.111.970814
6. American College of Radiology. ACR Appropriateness Criteria® Suspected Upper-Extremity Deep Vein Thrombosis. American College of Radiology. Updated 2019. Accessed January 25, 2023. https://acsearch.acr.org/docs/69417/Narrative/
7. Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A. Deep Vein Thrombosis of the Upper Extremity. Dtsch Arztebl Int. Apr 7 2017;114(14):244-249.doi:10.3238/arztebl.2017.0244
8. Bozlar U, Ogur T, Khaja MS, All J, Norton PT, Hagspiel KD. CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients. AJR Am J Roentgenol. Oct 2013;201(4):753-63. doi:10.2214/ajr.13.11208
9. Bozlar U, Ogur T, Norton PT, Khaja MS, All J, Hagspiel KD. CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients. AJR Am J Roentgenol. Oct 2013;201(4):745-52. doi:10.2214/ajr.13.11207
10. Jin T, Wu G, Li X, Feng X. Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: use of time-resolved 3D MR angiography at 3-T. Acta Radiol. May 2018;59(5):586-592. doi:10.1177/0284185117729185
11. Kransdorf MJ, Murphey MD, Wessell DE, et al. ACR Appropriateness Criteria(®) Soft-Tissue Masses. J Am Coll Radiol. May 2018;15(5s):S189-s197. doi:10.1016/j.jacr.2018.03.012
12. Wani ML, Ahangar AG, Ganie FA, Wani SN, Wani NU. Vascular injuries: trends in management. Trauma Mon. Summer 2012;17(2):266-9. doi:10.5812/traumamon.6238
13. Fonseka CL, Galappaththi SR, Abeyaratne D, Tissera N, Wijayaratne L. A Case of Polyarteritis Nodosa Presenting as Rapidly Progressing Intermittent Claudication of Right Leg. Case Rep Med. 2017;2017:4219718. doi:10.1155/2017/4219718
14. Verikokos C, Karaolanis G, Doulaptsis M, et al. Giant popliteal artery aneurysm: case report and review of the literature. Case Rep Vasc Med. 2014;2014:780561. doi:10.1155/2014/780561
15. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med. Sep 7 2010;153(5):325-34. doi:10.7326/0003-4819-153-5-201009070-00007
16. Rafailidis V, Li X, Chryssogonidis I, et al. Multimodality Imaging and Endovascular Treatment Options of Subclavian Steal Syndrome. Can Assoc Radiol J. Nov 2018;69(4):493-507. doi:10.1016/j.carj.2018.08.003
17. Murphy EA, Ross RA, Jones RG, et al. Imaging in Vascular Access. Cardiovasc Eng Technol. Sep 2017;8(3):255-272. doi:10.1007/s13239-017-0317-y
18. Madani H, Farrant J, Chhaya N, et al. Peripheral limb vascular malformations: an update of appropriate imaging and treatment options of a challenging condition. Br J Radiol. Mar 2015;88(1047):20140406. doi:10.1259/bjr.20140406
19. Obara P, McCool J, Kalva SP, et al. ACR Appropriateness Criteria® Clinically Suspected Vascular Malformation of the Extremities. J Am Coll Radiol. Nov 2019;16(11s):S340-s347. doi:10.1016/j.jacr.2019.05.013
20. Ahmed O, Hanley M, Bennett SJ, et al. ACR Appropriateness Criteria(®) Vascular Claudication-Assessment for Revascularization. J Am Coll Radiol. May 2017;14(5s):S372-s379. doi:10.1016/j.jacr.2017.02.037
21. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. Jun 2019;69(6s):3S-125S.e40. doi:10.1016/j.jvs.2019.02.016
22. Cooper K, Majdalany BS, Kalva SP, et al. ACR Appropriateness Criteria(®) Lower Extremity Arterial Revascularization-Post-Therapy Imaging. J Am Coll Radiol. May 2018;15(5s):S104-s115. doi:10.1016/j.jacr.2018.03.011
23. Weiss CR, Azene EM, Majdalany BS, et al. ACR Appropriateness Criteria(®) Sudden Onset of Cold, Painful Leg. J Am Coll Radiol. May 2017;14(5s):S307-s313. doi:10.1016/j.jacr.2017.02.015

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.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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