Aetna considers coil embolization medically necessary in the treatment of splenic artery aneurysm.
Aetna considers endovascular embolization is an acceptable treatment modality for an extracranial arteriovenous malformation or fistula.
Aetna considers renal artery embolization/angioinfarction, as a pre-operative adjunct to nephrectomy, medically necessary in the treatment of persons with large, hypervascular renal cell carcinomas.
Aetna considers transcatheter embolization (embolotherapy) medically necessary in the treatment of intractable or recurrent severe posterior epistaxis when conservative measures have failed.
Aetna considers tumor embolization or preoperative tumor embolization to reduce intraoperative bleeding prior to surgical resection medically necessary in the treatment of hypervascular tumors or metastases from hypervascular tumors.
Aetna considers alcohol embolization or sclerotherapy and/or surgery medically necessary for symptomatic venous malformations as evidenced by pain, swelling, ulceration, or hemorrhage.
Splenic artery aneurysms account for 60 % of all visceral arterial aneurysms. They are the only aneurysms that are more common in women, with a female-to-male ratio of 4:1. The development of aneurysms in the splenic artery has been attributed to systemic arterial fibrodysplasia, portal hypertension, and increased splenic arteriovenous shunting that occurs in pregnancy. Splenic artery aneurysms are most often asymptomatic. Symptomatic patients exhibit vague left upper quadrant or epigastric discomfort and occasional radiation of pain to the left shoulder or subscapular area. Only 2 % of splenic artery aneurysms result in life-threatening rupture.
Coil embolization is a catheter-based procedure that allows precise closure of abnormal blood flow in a blood vessel. A catheter with a metallic occluding coil is inserted into an artery, usually in the groin (the femoral artery). It is then advanced to the abnormal blood vessel. Once properly positioned, the metal coil is released, springing into position within the vessel. It remains firmly in place by the expansion of the metal coils. A blood clot will form on the coil, completely obstructing the abnormal blood flow beyond the coil. Eventually a scar will form, creating a permanent seal.
Although the individual study numbers are small, the total studied over several years is significant and the evidence has demonstrated that coil embolization in the treatment of splenic artery aneurysms is safe and effective and may induce less morbidity than open surgery, in particular by preserving the spleen.
Leffroy et al (2008) evaluated the outcomes of endovascular treatment of splenic artery aneurysms and pseudoaneurysms. From April 2002 to May 2007, 17 patients (mean age of 55.2 years, range of 17 to 82) with splenic artery aneurysms (n = 7) or pseudoaneurysms (n = 10) underwent endovascular treatment. Six patients were asymptomatic, 3 had symptomatic nonruptured aneurysms, and 8 had ruptured aneurysms. Lesions were in the proximal splenic artery (n = 5), intermediate splenic artery (n = 3), splenic hilum (n = 6), or parenchyma (n = 3). Embolization was with microcoils by sac packing (n = 8), sandwich occlusion of the main splenic artery (n = 4), or cyanoacrylate glue into the feeding artery (n = 4). Computed angiotomography was done within the first month and magnetic resonance angiography after 6 and 12 months, then yearly. Mean follow-up was 29 months (range of 1 to 62). Exclusion of the aneurysm was achieved in 16 (94.1 %) patients. One patient with an intra-parenchymal pseudoaneurysm underwent splenectomy after failed distal catheterization. No major complications occurred. Post-embolization syndrome developed in 4patients, who had radiographic evidence of splenic microinfarcts. The authors concluded that transcatheter embolization of splenic artery aneurysms/pseudoaneurysms is safe and effective and may induce less morbidity than open surgery, in particular by preserving the spleen. Coil artifacts may make magnetic resonance angiography preferable over computed tomography for follow-up.
Ikeda and colleagues (2008) described their experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and proposed indications for treating VAA by this method. a total of 22 patients with VAA were treated by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. The transcatheter coil embolization procedure included coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation. Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7 %) of the 22 patients and the native arterial circulation was preserved. Post-procedure angiograms confirmed complete disappearance of the VAA. In 4 of the 9 splenic artery aneurysm patients, the native arterial circulation was not preserved. In 1 renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean of 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in 1 splenic- and 2 renal artery aneurysms patients; the latter developed flank pain and fever after the procedure.
Yamamoto et al (2008) published the findings of a small study evaluating the clinical results and technical problems of transcatheter coil embolization for splenic artery aneurysm. Subjects were 16 patients (8 men, 8 women; age range of 40 to 80 years) who underwent transcatheter embolization for splenic artery aneurysm (14 true aneurysms, 2 false aneurysms) during the period January 1997 through July 2005. Embolic materials were fibered coils and interlocking detachable coils. Embolization was performed by the isolation technique, the packing technique, or both. Technically, all aneurysms were devascularized without severe complications. Embolized aneurysms were 6 to 40 mm in diameter (mean of 25 mm). Overall, the primary technical success rate was 88 % (14 of 16 patients). In the remaining 2 patients (12.5 %), partial recanalization occurred, and re-embolization was performed. The secondary technical success rate was 100 %. Seven (44 %) of the 16 study patients suffered partial splenic infarction. Intra-splenic branching originating from the aneurysm was observed in 5 patients. According to the authors, transcatheter coil embolization should be the initial treatment of choice for splenic artery aneurysm.
Piffaretti and associates (2007) assessed the endovascular embolization of splenic artery aneurysms and false aneurysms with special consideration given to postoperative complications in 15 patients (11 women; mean age of 56 years; range of 39 to 80 years) with splenic artery aneurysm (n = 13) or false aneurysm (n = 2) treated with coil embolization. The lesion was asymptomatic in 9 patients, symptomatic in 5 patients, ofnd ruptured in 1 patient. The mean aneurysm diameter was 33 +/- 23 mm (range of 15 to 80 mm). Post-operative follow-up evaluation included a clinical visit and spiral computed tomography at 1, 4, and 12 months, and yearly thereafter. Endovascular treatment was possible in 14 patients (93 %) (1 failure: neck cannulation). Peri-operative mortality was not observed. Morbidity included post-embolization syndrome in 5 patients (30 %). Neither pancreatitis nor spleen abscess occurred. The mean follow-up period was 36 months (range of 3 to 60 months). During follow-up evaluation 1 sac reperfusion was detected that was sealed successfully with additional coils. Surgical conversion or open repair were never required.
Tulsyan et al (2007) studied the outcomes of the management of visceral artery aneurysms with catheter-based techniques. Between 1997 and 2005, 90 patients were identified with a diagnosis of visceral artery aneurysm. This was inclusive of aneurysmal disease of the celiac axis, superior mesenteric artery (SMA), inferior mesenteric artery, and their branches. Surveillance without intervention occurred in 23 patients, and 19 patients underwent open aneurysm repair (4 ruptures). The endovascular treatment of 48 consecutive patients (mean age of 58, 60 % men) with 20 visceral artery aneurysms (VAA) and 28 visceral artery pseudoaneurysms (VAPA) was the basis for this study. Electronic and hardcopy medical records were reviewed for demographic data and clinical variables. Original computed tomography (CT) scans and fluoroscopic imaging were evaluated. The endovascular treatment of visceral artery aneurysms was technically successful in 98 % of 48 procedures, consisting of 3 celiac axis repairs, 2 left gastric arteries, 1 SMA, 12 hepatic arteries, 20 splenic arteries, 7 gastroduodenal arteries, 1 middle colic artery, and 2 pancreaticoduodenal arteries. Of these, 29 (60 %) were performed for symptomatic disease (5 ruptured aneurysms). Coil embolization was used for aneurysm exclusion in 96 %. N-butyl-2-cyanoacrylate (glue) was used selectively (19 %) using a triaxial system with a 3F microcatheter for persistent flow or multiple branches. The 30-day mortality was 8.3 % (n = 4). All peri-operative deaths occurred in patients requiring urgent or emergent intervention in the setting of hemodynamic instability. No patients undergoing elective intervention died in the peri-procedural period. Post-procedural imaging was performed after 77 % of interventions at a mean of 16 months. Complete exclusion of flow within the aneurysm sac occurred in 97 % interventions with follow-up imaging, but coil and glue artifact complicated CT evaluation. Post-embolization syndrome developed in 3 patients (6 %) after splenic artery embolization. There was no evidence of hepatic insufficiency or bowel ischemia after either hepatic or mesenteric artery aneurysm treatment. Three patients required secondary interventions for persistent flow (n = 1) and recurrent bleeding from previously embolized aneurysms (n = 2).
Gabelmann et al (2002) conducted a review of their 10-year experience with endovascular embolization of visceral artery aneurysms. A total of 25 patients (13 men; mean age of 52.1 years, range of 31 to 80) presented with VAAs of varying locations and etiologies: 10 splenic, 3 gastroduodenal, 2 pancreaticoduodenal, 3 hepatic, 3 superior mesenteric, 2 celiac, 1 left gastric, and 1 jejunoileal. Ten patients were asymptomatic; 7 aneurysms were ruptured. Transcatheter coil embolization was the treatment of choice in all patients. Coil placement was initially (less than 7 days) successful in 23 (92 %) patients. One superior mesenteric artery aneurysm remained perfused, and recurrent bleeding occurred 2 days after intervention in 1 case, but repeated embolization excluded the aneurysm. One patient with necrotizing pancreatitis died from sepsis 10 days after endovascular treatment and surgery (4 % 30-day mortality). Long-term follow-up revealed excellent results after an average 48.7 months (range of 14 to 75) with only 1 recurrence after 12 months.
Guillon et al (2003) assessed the endovascular treatment of 12 patients (mean age of 59 years, range of 47 to 75 years) with splenic artery aneurysm (n = 10) or false aneurysm (n = 2). The lesion was asymp)omatic in 11 patients; hemobilia was observed in 1 patient. The lesion was juxta-ostial in 1 case, located on the intermediate segment of the splenic artery in 4, near the splenic hilus in 6, and affected the whole length of the artery in 1 patient. In 10 cases, the maximum lesion diameter was greater than 2 cm; in 1 case 30 % growth of an aneurysm 18 mm in diameter had occurred in 6 months; in the last case, 2 distal aneurysms were associated (17 and 18 mm in diameter). In 1 case, stent-grafting was attempted; 1 detachable balloon occlusion was performed; the 10 other patients were treated with coils. Endovascular treatment was possible in 11 patients (92 %) (1 failure: stenting attempt). In 4 cases among 11, the initial treatment was not successful (residual perfusion of aneurysm); surgical treatment was carried out in 1 case, and a second embolization in 2. Thus, in 9 cases (75 %) endovascular treatment was successful: complete and persistent exclusion of the aneurysm but with spleen perfusion persisting at the end of follow-up on CT scans (mean of 13 months). An early and transient elevation of pancreatic enzymes was observed in 4 cases.
Arteriovenous malformation (AVM) is a disorder of the blood vessels that is characterized by a complex, tangled web of abnormal arteries and veins connected by 1 or more AV (arteriovenous) fistulas (abnormal communications). AVMs of the hemangioma type are congenital. While they can occur anywhere in the body and have been found in the arms, hands, legs, feet, lungs, heart, liver, and kidneys; 50 % of these malformations occur in the brain, brainstem, and spinal cord. AVMs of the intestine, also referred to as angiodysplasias, are distinct from hemangiomas and true congenital AVMs. They are thought to be acquired degenerative lesions secondary to progressive dilation of normal blood vessels within the submucosa of the intestine. An arteriovenous malformation may hemorrhage, or bleed, leading to serious complications that can be life threatening.
Endovascular embolization is the therapeutic introduction of various substances or other materials, into the circulation, to occlude blood vessels. This is intended to either arrest or prevent bleeding, or devitalize a structure, tumor or organ by occluding it’s blood supply.
Various embolization devices and several types of embolic agents have been approved by the U.S. Food and Drug Administration. The currently available embolic agents include liquid embolitics, particulate materials, metallic coils, and detachable balloons. There are numerous liquid embolic agents, the most commonly used being absolute alcohol (100 % ethanol) and various tissue adhesives, including the cyanoacrylates and Onyx (EV3 Neurovascular). Two commonly used particulate materials are Gelfoam and polyvinyl alcohol (PVA).
There are 2 broad categories of metallic coils: coils that are pushed from a catheter with a metal coil pusher or guidewire, and coils that are released by breaking a bond between the coil and the pushing wire.
Based on the clinical evidence, endovascular embolization is an acceptable treatment modality for an extra-cranial arteriovenous malformation or fistula.
Renal cell cancer accounts for 90 to 95 % of malignant neoplasms arising from the kidney. Gross or microscopic hematuria is the most common presenting sign, followed by abdominal pain and a flank or abdominal mass.
Renal artery embolization is a non-surgical technique. Using x-rays (angiography), a catheter is directed into the renal artery by a specially trained radiologist (Interventional Radiologist). Material is injected through the catheter into the artery causing the blood to clot and block blood flow to the kidney. Nephrectomy is the surgical procedure to remove a kidney.
Based on the clinical evidence, renal artery embolization/angioinfarction, as a preoperative adjunct to nephrectomy, is an acceptable alternative in the treatment of patients with large, hypervascular renal cell carcinomas.
Epistaxis is bleeding from the nose or nasal hemorrhage and is classified as anterior or posterior. Approximately 90 % of epistaxis events are idiopathic. Transcatheter embolization (embolotherapy) is the intentional occlusion of a vessel by deposition of thrombogenic materials directly into the vessel via an angiographic catheter. Based on the clinical evidence, transcatheter embolization (embolotherapy) is an acceptable alternative in the treatment of intractable or recurrent severe posterior epistaxis when conservative measures have failed.
A hypervascular tumor is a tumor characterized by an abnormal increase in blood vessel growth in the area. These vessels feed the tumor cells, and may be characterized by abnormal connections between veins and arteries. Hypervascular tumors may be benign (meningiomas, osteoblastomas, chondromas), malignant (renal cell carcinoma, thyroid carcinoma, hepatocellular carcinoma, glomus tumor) or metastatic tumors from these primary sites (list is not all-inclusive).
Tumor embolization is defined as the blockage of the vascular supply to a tumor. Embolization is the therapeutic introduction of various substances into the circulation to occlude vessels, either to arrest or prevent hemorrhaging, to devitalize a structure tumor or organ by occluding it’s blood supply or to reduce blood flow an arteriovenous malformation. The occlusion is usually performed via an endovascular approach, transcatheter embolization (embolotherapy) by deposition of thrombogenic materials directly into the vessel via an angiographic catheter or by direct percutaneous injection of embolic agents into the tumor. The goals of embolization may be adjunctive, curative, or palliative. The procedure is usually performed in a single session, simultaneously with diagnostic arteriography, but may also be performed in multiple staged sessions. Pre-operative embolization is also performed.
Tumor embolization or preoperative tumor embolization to reduce intra-operative bleeding prior to surgical resection may be considered medically necessary in the treatment of hypervascular tumors or metastases from hypervascular tumors.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met :
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)
for tumors, organ ischemia, or infarction
for arterial or venous hemorrhage or lymphatic extravasation
Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord)
Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch)
Transcatheter therapy, embolization, any method, radiological supervision and interpretation
ICD-9 codes covered if selection criteria are met:
Malignant neoplasm of liver, primary [hepatocellular carcinoma]
Malignant neoplasm of kidney, except pelvis [renal cell carcinoma]
Aneurysm of splenic artery
Congenital anomaly of the peripheral vascular system, unspecified site
Epistaxis [intractable or recurrent severe posterior]
The above policy is based on the following references:
Splenic Artery Aneurysm
Gabelmann A, Gorich J, Merkle EM. Endovascular treatment of visceral artery aneurysms. J Endovasc Ther. 2002;9:38-47.
Grainger and Allison’s Diagnostic Radiology: A Textbook of Medical Imaging. 4th Edition. 2001.
Guillon R, et al. Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients. Cardiovasc Intervent Radiol.2003;26(3):256-260.
Ikeda O, et al. Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization. J Vasc Surg. 2008;47(6):1212-1219.
Liu CF, Kung CT, Liu BM, et al. Splenic artery aneurysms encountered in the ED: 10 years’ experience. Am J Emerg Med. 2007;25(4):430-436.
Loffroy R, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: Short- and long-term results. Ann Vasc Surg. 2008;22(5):618-626.
Piffaretti et al. Splenic artery aneurysms: postembolization syndrome and surgical complications. Am J Surg. 2007;193(2):166-170.
Townsend: Sabiston Textbook of Surgery. 19th Edition. 2012.
Tulsyan N, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg, 42007;5(2):276-283; discussion 283.
U.S. Food and Drug Administration website.
Yamamoto S, et al. Transcatheter coil embolization of splenic artery aneurysm. Cardiovasc Intervent Radiol. 2008;31(3):527-534.
Extracranial Embolization for AV Malformations or Fistulae
Hayes WS, et al. Onyx® Liquid Embolic System (ev3 Inc.) for Treatment of cranial and spinal arteriovenous malformations. Technology Brief. November 2006. November 2007. December 2008. Archived December 17, 2009.
Hsieh KS, et al. Coronary artery fistulas in neonates, infants and children: Clinical findings and outcomes. Pediatr Cardiol. 2002;23(4):415-419.
Hsu CC, Kwan GN, Thompson SA, van Driel ML. Embolisation therapy for pulmonary arteriovenous malformations. Cochrane Database Syst Rev. 2010;(5):CD008017.
Jin Y, et al. Auricular arteriovenous malformations: Potential success of superselective ethanol embolotherapy. J Vasc Interv Radiol. 2009;20(6):736-743.
Kliegman: Nelson Textbook of Pediatrics. 18th Edition. 2007.
Lacombe P1, Lagrange C, Beauchet A, et al. Diffuse pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia. Chest. 2009;135(4):1031-1037.
Liang CD, Ko SF. Midterm outcome of percutaneous transcatheter coil occlusion of coronary artery fistula. Pediatr Cardiol. 2006;27(5):557-563
Libby: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8h Edition. 2007.
Liu AS, et al. Extracranial arteriovenous malformations: Natural progression and recurrence after treatment. Plast Reconstr Surg. 2010;125(4):1185-1194.
Mandell VS. Interventional procedures for congenital heart disease. Radiol Clin North Am. 1999;37(2):439-461.
Mason: Murray and Nadel's Textbook of Respiratory Medicine. 5th Edition. 2010.
Mavroudis C, et al. Coronary artery fistulas in infants and children: A surgical review and discussion of coil embolization. Ann Thorac Surg. 1997;63(5):1235-1242.
McMahon CJ, et al. Coronary artery fistula. Management and intermediate-term outcome after transcatheter coil occlusion. Tex Heart Inst J. 2001;28(1):21-25.
Milic A, et al. Reperfusion of pulmonary arteriovenous malformations after embolotherapy. J Vasc Interv Radiol. 2005;16(12):1675-1683.
Nakamura H, et al. Renal arteriovenous malformations: Transcatheter embolization and follow-up. AM J Roentgenol. 1981;137(1):113-116.
Perry SB, et al. Transcatheter closure of coronary artery fistulas. J Am Coll Cardiol. 1992;20(1):205-209.
Post MC, Thijs V, Schonewille WJ, et al. Embolization of pulmonary arteriovenous malformations and decrease in prevalence of migraine. Neurology. 2006;66(2):202-205.
Qureshi SA, Tynan M. Catheter closure of coronary artery fistulas, J Interv Cardiol. 2001;14(3):299-307.
Remy-Jardin M, et al. Pulmonary arteriovenous malformations treated with embolotherapy: Helical CT evaluation of long-term effectiveness after 2-21-year follow-up. Radiology. 2006;239(2):576-585.
Reidy JF, et al. Catheter embolization in the treatment of coronary artery fistulas. J Am Coll Cardiol. 1991;18(1):187-192.
Takebayashi S, et al. Transarterial embolization and ablation of renal arteriovenous malformations: Efficacy and damages in 30 patients with long-term followup. J Urol. 1998;159(3):696-701.
Bakal CW, et al. Value of preoperative renal artery embolization in reducing blood transfusion requirements during nephrectomy for renal cell carcinoma. J Vasc Interv Radiol. 1993;4(6):727-731.
Brenner and Rector’s The Kidney. 7th Edition. 2004.
Grainer & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging. 4th Edition. 2001.
Kaisary AV, Williams G, Riddle PR. The role of preoperative embolization in renal cell carcinoma. J Urol. 1984;131(4):641-646.
Klimberg I, et al. Preoperative angioinfarction of localized renal cell carcinoma using absolute ethanol. J Urol. 1985;133(1):21-24.
National Cancer Institute. Renal Cell Carcinoma PDQ. June 2003.
Singsaas MW, Chopp RT, Mendez R. Preoperative renal embolization as adjunct to radical nephrectomy. Urology. 1979;4(1):1-4.
Walsh: Campbell’s Urology. 8th Edition. 2002.
Zielinski H, Szmigielski S, Petrovich Z. Comparison of preoperative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma. Am J Clin Oncol. 2000;23(1):6-12.
Vogel TR, et al. Carotid body tumor surgery: Management and outcomes in the nation. Vasc Endovascular Surg. 2009;43(5):457-461.
Walsh: Palliative Medicine. 1st Edition. 2008.
Zielinski H, et al. Comparison of preoperative embolization followed by radical nephrectomy with radical nephrectomy alone for renal cell carcinoma. Am J Clin Oncol. 2000;23(1):6-12.
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