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Nowak E, Białecki M, Białecka A, Kazimierczak N, Kloska A. Assessing the diagnostic accuracy of artificial intelligence in post-endovascular aneurysm repair endoleak detection using dual-energy computed tomography angiography. Pol J Radiol 2024; 89:e420-e427. [PMID: 39257927 PMCID: PMC11384217 DOI: 10.5114/pjr/192115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 09/12/2024] Open
Abstract
Purpose The aim of this study was to evaluate the diagnostic accuracy of an artificial intelligence (AI) tool in detecting endoleaks in patients undergoing endovascular aneurysm repair (EVAR) using dual-energy computed tomography angiography (CTA). Material and methods The study involved 95 patients who underwent EVAR and subsequent CTA follow-up. Dualenergy scans were performed, and images were reconstructed as linearly blended (LB) and 40 keV virtual monoenergetic (VMI) images. The AI tool PRAEVAorta®2 was used to assess arterial phase images for endoleaks. Two experienced readers independently evaluated the same images, and their consensus served as the reference standard. Key metrics, including accuracy, precision, recall, F1 score, and area under the receiver operating characteristic (ROC) curve (AUC), were calculated. Results The final analysis included 94 patients. The AI tool demonstrated an accuracy of 78.7%, precision of 67.6%, recall of 10 71.9%, F1 score of 69.7%, and an AUC of 0.77 using LB images. However, the tool failed to process 40 keV VMI images correctly, limiting further analysis of these datasets. Conclusions The AI tool showed moderate diagnostic accuracy in detecting endoleaks using LB images but failed to achieve the reliability needed for clinical use due to the significant number of misdiagnoses.
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Affiliation(s)
- Ewa Nowak
- Department of Radiology and Diagnostic Imaging, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Białecki
- Department of Radiology and Diagnostic Imaging, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
- Department of Radiology and Diagnostic Imaging, University Hospital no. 1 in Bydgoszcz, Poland
| | - Agnieszka Białecka
- Department of Dermatology and Venereology, Collegium Medicum, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | | | - Anna Kloska
- Faculty of Medicine, Bydgoszcz University of Science and Technology, Bydgoszcz, Poland
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Cai H, Jiang H, Xie D, Lai Z, Wu J, Chen M, Yang Z, Xu R, Zeng S, Ma H. Enhancing image quality in computed tomography angiography follow-ups after endovascular aneurysm repair: a comparative study of reconstruction techniques. BMC Med Imaging 2024; 24:162. [PMID: 38956470 PMCID: PMC11218285 DOI: 10.1186/s12880-024-01343-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/20/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND The image quality of computed tomography angiography (CTA) images following endovascular aneurysm repair (EVAR) is not satisfactory, since artifacts resulting from metallic implants obstruct the clear depiction of stent and isolation lumens, and also adjacent soft tissues. However, current techniques to reduce these artifacts still need further advancements due to higher radiation doses, longer processing times and so on. Thus, the aim of this study is to assess the impact of utilizing Single-Energy Metal Artifact Reduction (SEMAR) alongside a novel deep learning image reconstruction technique, known as the Advanced Intelligent Clear-IQ Engine (AiCE), on image quality of CTA follow-ups conducted after EVAR. MATERIALS This retrospective study included 47 patients (mean age ± standard deviation: 68.6 ± 7.8 years; 37 males) who underwent CTA examinations following EVAR. Images were reconstructed using four different methods: hybrid iterative reconstruction (HIR), AiCE, the combination of HIR and SEMAR (HIR + SEMAR), and the combination of AiCE and SEMAR (AiCE + SEMAR). Two radiologists, blinded to the reconstruction techniques, independently evaluated the images. Quantitative assessments included measurements of image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), the longest length of artifacts (AL), and artifact index (AI). These parameters were subsequently compared across different reconstruction methods. RESULTS The subjective results indicated that AiCE + SEMAR performed the best in terms of image quality. The mean image noise intensity was significantly lower in the AiCE + SEMAR group (25.35 ± 6.51 HU) than in the HIR (47.77 ± 8.76 HU), AiCE (42.93 ± 10.61 HU), and HIR + SEMAR (30.34 ± 4.87 HU) groups (p < 0.001). Additionally, AiCE + SEMAR exhibited the highest SNRs and CNRs, as well as the lowest AIs and ALs. Importantly, endoleaks and thrombi were most clearly visualized using AiCE + SEMAR. CONCLUSIONS In comparison to other reconstruction methods, the combination of AiCE + SEMAR demonstrates superior image quality, thereby enhancing the detection capabilities and diagnostic confidence of potential complications such as early minor endleaks and thrombi following EVAR. This improvement in image quality could lead to more accurate diagnoses and better patient outcomes.
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Affiliation(s)
- Huasong Cai
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Hairong Jiang
- Department of Radiology, Foresea Life Insurance Guangzhou General Hospital, No. 703, Xincheng Avenue, Zengcheng District, Guangzhou, Guangdong, 511300, China
| | - Dingxiang Xie
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Zhiman Lai
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Jiale Wu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Mingjie Chen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Zhiyun Yang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Rulin Xu
- Research Collaboration, Canon Medical Systems, No.10 Huaxia Road, Guangzhou, Guangdong, 510623, China
| | - Shanmei Zeng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China.
| | - Hui Ma
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China.
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Tarkowski P, Siek E, Staśkiewicz G, Bielecki DK, Czekajska-Chehab E. Angle Dependence of Electrode Lead-Related Artifacts in Single- and Dual-Energy Cardiac ECG-Gated CT Scanning-A Phantom Study. J Clin Med 2024; 13:3746. [PMID: 38999312 PMCID: PMC11242805 DOI: 10.3390/jcm13133746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 06/19/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The electrodes of implantable cardiac devices (ICDs) may cause significant problems in cardiac computed tomography (CT) because they are a source of artifacts that obscure surrounding structures and possible pathology. There are a few million patients currently with ICDs, and some of these patients will require cardiac imaging due to coronary artery disease or problems with ICDs. Modern CT scanners can reduce some of the metal artifacts because of MAR software, but in some vendors, it does not work with ECG gating. Introduced in 2008, dual-energy CT scanners can generate virtual monoenergetic images (VMIs), which are much less susceptible to metal artifacts than standard CT images. Objective: This study aimed to evaluate if dual-energy CT can reduce metal artifacts caused by ICD leads by using VMIs. The second objective was to determine how the angle between the electrode and the plane of imaging affects the severity of the artifacts in three planes of imaging. Methods: A 3D-printed model was constructed to obtain a 0-90-degree field at 5-degree intervals between the electrode and each of the planes: axial, coronal, and sagittal. This electrode was scanned in dual-energy and single-energy protocols. VMIs with an energy of 40-140 keV with 10 keV intervals were reconstructed. The length of the two most extended artifacts originating from the tip of the electrode and 2 cm above it-at the point where the thick metallic defibrillating portion of the electrode begins-was measured. Results: For the sagittal plane, these observations were similar for both points of the ICDs that were used as the reference location. VMIs with an energy over 80 keV produce images with fewer artifacts than similar images obtained in the single-energy scanning mode. Conclusions: Virtual monoenergetic imaging techniques may reduce streak artifacts arising from ICD electrodes and improve the quality of the image. Increasing the angle of the electrode as well as the imaging plane can reduce artifacts. The angle between the electrode and the beam of X-rays can be increased by tilting the gantry of the scanner or lifting the upper body of the patient.
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Affiliation(s)
- Piotr Tarkowski
- Department of Radiology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Elżbieta Siek
- Department of Clinical and Radiological Anatomy, Medical University of Lublin, 20-090 Lublin, Poland
- Department of Radiology and Nuclear Medicine, University Hospital No 4, 20-090 Lublin, Poland
| | - Grzegorz Staśkiewicz
- Department of Clinical and Radiological Anatomy, Medical University of Lublin, 20-090 Lublin, Poland
- Department of Radiology and Nuclear Medicine, University Hospital No 4, 20-090 Lublin, Poland
| | - Dennis K Bielecki
- Department of Diagnostic Imaging, Kings College Hospital, London SE5 9RS, UK
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Wajer R, Wajer A, Kazimierczak N, Wilamowska J, Serafin Z. The Impact of AI on Metal Artifacts in CBCT Oral Cavity Imaging. Diagnostics (Basel) 2024; 14:1280. [PMID: 38928694 PMCID: PMC11203150 DOI: 10.3390/diagnostics14121280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE This study aimed to assess the impact of artificial intelligence (AI)-driven noise reduction algorithms on metal artifacts and image quality parameters in cone-beam computed tomography (CBCT) images of the oral cavity. MATERIALS AND METHODS This retrospective study included 70 patients, 61 of whom were analyzed after excluding those with severe motion artifacts. CBCT scans, performed using a Hyperion X9 PRO 13 × 10 CBCT machine, included images with dental implants, amalgam fillings, orthodontic appliances, root canal fillings, and crowns. Images were processed with the ClariCT.AI deep learning model (DLM) for noise reduction. Objective image quality was assessed using metrics such as the differentiation between voxel values (ΔVVs), the artifact index (AIx), and the contrast-to-noise ratio (CNR). Subjective assessments were performed by two experienced readers, who rated overall image quality and artifact intensity on predefined scales. RESULTS Compared with native images, DLM reconstructions significantly reduced the AIx and increased the CNR (p < 0.001), indicating improved image clarity and artifact reduction. Subjective assessments also favored DLM images, with higher ratings for overall image quality and lower artifact intensity (p < 0.001). However, the ΔVV values were similar between the native and DLM images, indicating that while the DLM reduced noise, it maintained the overall density distribution. Orthodontic appliances produced the most pronounced artifacts, while implants generated the least. CONCLUSIONS AI-based noise reduction using ClariCT.AI significantly enhances CBCT image quality by reducing noise and metal artifacts, thereby improving diagnostic accuracy and treatment planning. Further research with larger, multicenter cohorts is recommended to validate these findings.
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Affiliation(s)
- Róża Wajer
- Department of Radiology and Diagnostic Imaging, University Hospital No. 1 in Bydgoszcz, Marii Skłodowskiej—Curie 9, 85-094 Bydgoszcz, Poland; (J.W.); (Z.S.)
| | | | - Natalia Kazimierczak
- Kazimierczak Private Medical Practice, Dworcowa 13/u6a, 85-009 Bydgoszcz, Poland;
| | - Justyna Wilamowska
- Department of Radiology and Diagnostic Imaging, University Hospital No. 1 in Bydgoszcz, Marii Skłodowskiej—Curie 9, 85-094 Bydgoszcz, Poland; (J.W.); (Z.S.)
- Department of Radiology and Diagnostic Imaging, Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067 Bydgoszcz, Poland
| | - Zbigniew Serafin
- Department of Radiology and Diagnostic Imaging, University Hospital No. 1 in Bydgoszcz, Marii Skłodowskiej—Curie 9, 85-094 Bydgoszcz, Poland; (J.W.); (Z.S.)
- Department of Radiology and Diagnostic Imaging, Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067 Bydgoszcz, Poland
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Stański M, Michałowska I, Lemanowicz A, Karmelita-Katulska K, Ratajczak P, Sławińska A, Serafin Z. Dual-Energy and Photon-Counting Computed Tomography in Vascular Applications-Technical Background and Post-Processing Techniques. Diagnostics (Basel) 2024; 14:1223. [PMID: 38928639 PMCID: PMC11202784 DOI: 10.3390/diagnostics14121223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/30/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
The field of computed tomography (CT), which is a basic diagnostic tool in clinical practice, has recently undergone rapid technological advances. These include the evolution of dual-energy CT (DECT) and development of photon-counting computed tomography (PCCT). DECT enables the acquisition of CT images at two different energy spectra, which allows for the differentiation of certain materials, mainly calcium and iodine. PCCT is a recent technology that enables a scanner to quantify the energy of each photon gathered by the detector. This method gives the possibility to decrease the radiation dose and increase the spatial and temporal resolutions of scans. Both of these techniques have found a wide range of applications in radiology, including vascular studies. In this narrative review, the authors present the principles of DECT and PCCT, outline their advantages and drawbacks, and briefly discuss the application of these methods in vascular radiology.
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Affiliation(s)
- Marcin Stański
- Department of General Radiology and Neuroradiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Ilona Michałowska
- Department of Radiology, National Institute of Cardiology, 04-628 Warsaw, Poland;
| | - Adam Lemanowicz
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland; (A.L.); (P.R.); (A.S.); (Z.S.)
| | - Katarzyna Karmelita-Katulska
- Department of General Radiology and Neuroradiology, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Przemysław Ratajczak
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland; (A.L.); (P.R.); (A.S.); (Z.S.)
| | - Agata Sławińska
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland; (A.L.); (P.R.); (A.S.); (Z.S.)
| | - Zbigniew Serafin
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum, 85-067 Bydgoszcz, Poland; (A.L.); (P.R.); (A.S.); (Z.S.)
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Abesi F, Talachi F, Ezoji F. Performance of different cone-beam computed tomography scan modes with and without metal artifact reduction in detection of recurrent dental caries under various restorative materials. Pol J Radiol 2024; 89:e281-e291. [PMID: 39040560 PMCID: PMC11262014 DOI: 10.5114/pjr/188257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/03/2024] [Indexed: 07/24/2024] Open
Abstract
Purpose We aimed to compare the diagnostic performance of different cone-beam computed tomography (CBCT) scan modes with and without the application of a metal artifact reduction (MAR) option under 5 different restorative materials. Material and methods Our research was an in vitro study with 150 caries-free premolars and molars. The teeth were randomly divided into experimental (with artificially induced caries, n = 75) and control (without caries, n = 75) groups and were prepared based on 5 types of restorative materials, including conventional composites (Filtek Z250, Gradia), flow composite, glass ionomer, and amalgam. The teeth were examined under 2 CBCT scan modes (high-resolution [HIRes] and standard) with and without MAR application. Finally, the diagnostic accuracy index values (area under the receiver operating characteristic curve [AUC], sensitivity, and specificity) were calculated. Results The AUC of standard scan mode with the MAR option was significantly lower than that of HIRes with MAR (p = 0.018) and without MAR option (p = 0.011) in detecting recurrent caries. Also, without MAR option, the diagnostic accuracy (AUC) of the standard mode was significantly lower than that of the HIRes (p = 0.020). Similar findings were observed for sensitivity and specificity. Moreover, diagnostic performance of standard and HIRes scan modes with and without MAR in the amalgam group was lower than that in other restorative material groups. Conclusions Diagnostic performance of HIRes CBCT mode was higher than that of standard mode for recurrent caries and remained unaffected by MAR application. However, the accuracy in detecting recurrent caries was lower in the amalgam group compared with other restorative material groups.
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Affiliation(s)
- Farida Abesi
- Dental Materials Research Centre, Department of Oral and Maxillofacial Radiology, Dental Faculty, Babol University of Medical Sciences, Babol, Iran
| | | | - Fariba Ezoji
- Dental Materials Research Centre, Health Research Institute, Faculty of Dentistry, Babol University of Medical Sciences, Babol, Iran
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Kazimierczak W, Kazimierczak N, Wilamowska J, Wojtowicz O, Nowak E, Serafin Z. Enhanced visualization in endoleak detection through iterative and AI-noise optimized spectral reconstructions. Sci Rep 2024; 14:3845. [PMID: 38360941 PMCID: PMC10869818 DOI: 10.1038/s41598-024-54502-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/13/2024] [Indexed: 02/17/2024] Open
Abstract
To assess the image quality parameters of dual-energy computed tomography angiography (DECTA) 40-, and 60 keV virtual monoenergetic images (VMIs) combined with deep learning-based image reconstruction model (DLM) and iterative reconstructions (IR). CT scans of 28 post EVAR patients were enrolled. The 60 s delayed phase of DECTA was evaluated. Objective [noise, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR)] and subjective (overall image quality and endoleak conspicuity - 3 blinded readers assessment) image quality analyses were performed. The following reconstructions were evaluated: VMI 40, 60 keV VMI; IR VMI 40, 60 keV; DLM VMI 40, 60 keV. The noise level of the DLM VMI images was approximately 50% lower than that of VMI reconstruction. The highest CNR and SNR values were measured in VMI DLM images. The mean CNR in endoleak in 40 keV was accounted for as 1.83 ± 1.2; 2.07 ± 2.02; 3.6 ± 3.26 in VMI, VMI IR, and VMI DLM, respectively. The DLM algorithm significantly reduced noise and increased lesion conspicuity, resulting in higher objective and subjective image quality compared to other reconstruction techniques. The application of DLM algorithms to low-energy VMIs significantly enhances the diagnostic value of DECTA in evaluating endoleaks. DLM reconstructions surpass traditional VMIs and IR in terms of image quality.
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Affiliation(s)
- Wojciech Kazimierczak
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067, Bydgoszcz, Poland.
- Kazimierczak Private Medical Practice, Dworcowa 13/u6a, 85-009, Bydgoszcz, Poland.
- University Hospital No 1 in Bydgoszcz, Marii Skłodowskiej - Curie 9, 85-094, Bydgoszcz, Poland.
| | - Natalia Kazimierczak
- Kazimierczak Private Medical Practice, Dworcowa 13/u6a, 85-009, Bydgoszcz, Poland
| | - Justyna Wilamowska
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067, Bydgoszcz, Poland
- University Hospital No 1 in Bydgoszcz, Marii Skłodowskiej - Curie 9, 85-094, Bydgoszcz, Poland
| | - Olaf Wojtowicz
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067, Bydgoszcz, Poland
- University Hospital No 1 in Bydgoszcz, Marii Skłodowskiej - Curie 9, 85-094, Bydgoszcz, Poland
| | - Ewa Nowak
- University Hospital No 1 in Bydgoszcz, Marii Skłodowskiej - Curie 9, 85-094, Bydgoszcz, Poland
| | - Zbigniew Serafin
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067, Bydgoszcz, Poland
- University Hospital No 1 in Bydgoszcz, Marii Skłodowskiej - Curie 9, 85-094, Bydgoszcz, Poland
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Kazimierczak W, Kazimierczak N, Serafin Z. Review of Clinical Applications of Dual-Energy CT in Patients after Endovascular Aortic Repair. J Clin Med 2023; 12:7766. [PMID: 38137834 PMCID: PMC10743598 DOI: 10.3390/jcm12247766] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/08/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Abdominal aortic aneurysms (AAAs) are a significant cause of mortality in developed countries. Endovascular aneurysm repair (EVAR) is currently the leading treatment method for AAAs. Due to the high sensitivity and specificity of post-EVAR complication detection, CT angiography (CTA) is the reference method for imaging surveillance in patients after EVAR. Many studies have shown the advantages of dual-energy CT (DECT) over standard polyenergetic CTA in vascular applications. In this article, the authors briefly discuss the technical principles and summarize the current body of literature regarding dual-energy computed tomography angiography (DECTA) in patients after EVAR. The authors point out the most useful applications of DECTA in this group of patients and its advantages over conventional CTA. To conduct this review, a search was performed using the PubMed, Google Scholar, and Web of Science databases.
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Affiliation(s)
- Wojciech Kazimierczak
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067 Bydgoszcz, Poland
- Kazimierczak Private Medical Practice, Dworcowa 13/u6a, 85-009 Bydgoszcz, Poland
| | - Natalia Kazimierczak
- Kazimierczak Private Medical Practice, Dworcowa 13/u6a, 85-009 Bydgoszcz, Poland
| | - Zbigniew Serafin
- Collegium Medicum, Nicolaus Copernicus University in Torun, Jagiellońska 13-15, 85-067 Bydgoszcz, Poland
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