Is endovascular repair of aortic diseases using FDA-approved fenestrated, branched, or non-fenestrated endovascular stent graft medically indicated for a patient with aneurysmal dilation of the common iliac artery and moderate calcification of the aorta?

Endovascular Repair is NOT Medically Necessary for This Patient

Based on current guideline thresholds, this 70-year-old male does NOT meet criteria for endovascular aortic-iliac repair, as his infrarenal aorta measures 4.3 cm and common iliac arteries measure 2.9 cm, both well below intervention thresholds. The procedures CPT 34705,34717, and associated inpatient stay are not medically indicated at this time.

Size Criteria Not Met

The patient's imaging demonstrates:

• Infrarenal aorta: 4.3 x 3.7 cm - This is below the intervention threshold of ≥55 mm (5.5 cm) for men with abdominal aortic aneurysm 1
• Right common iliac artery: 2.9 cm - This is below the typical intervention threshold
• Left common iliac artery: aneurysmal dilation (specific measurement not provided, but described as dilated)

The 2024 ESC Guidelines clearly state that no benefits from open or endovascular interventions occur in asymptomatic AAA patients with maximal diameter <55 mm in men 1. The 2022 ACC/AHA Guidelines support intervention for infrarenal AAA when diameter exceeds 5.5 cm 1.

Common Iliac Artery Considerations

While the patient has aneurysmal dilation of the left common iliac artery, the right common iliac artery measures only 2.9 cm. Isolated common iliac artery aneurysms typically warrant intervention at ≥3.0-3.5 cm, and this patient's measurements fall at or below this threshold 1.

The presence of "moderately soft eccentric plaque" does not change size-based intervention criteria 1.

Absence of High-Risk Features

The patient lacks features that would justify intervention below standard thresholds:

• No rapid growth documented - Guidelines recommend intervention for confirmed rapid aneurysm growth (≥5 mm in 6 months or ≥10 mm per year) regardless of absolute diameter 1, 2
• No symptoms attributable to aneurysm - The clinical information describes chronic venous insufficiency and leg wounds, which are unrelated to aortic pathology 1
• No saccular morphology - Saccular aneurysms warrant intervention regardless of diameter due to higher rupture risk 1

Recommended Management

Surveillance imaging is the appropriate management strategy:

• Initial follow-up imaging at 6-12 months to establish growth rate 1
• Annual surveillance if stable, with intervention reconsidered if growth rate exceeds 0.5 cm/year or diameter reaches threshold 1
• Address venous insufficiency through appropriate conservative and medical management, which is unrelated to aortic dimensions

Critical Pitfall to Avoid

The presence of chronic venous insufficiency and leg wounds should not be conflated with aortic pathology. These are separate vascular issues requiring different management strategies. Performing endovascular aortic repair will not address the patient's leg swelling or wounds 1.

Insurance Criteria Alignment

The documentation correctly notes that the patient "DOES NOT MEET LISTED" criteria per Aetna CPB 0651 for endovascular repair of infrarenal abdominal aortic or aorto-iliac aneurysms. This aligns with evidence-based guideline recommendations 1.