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Henning MK, Aaløkken TM, Martinsen AC, Johansen S. The impact of body compositions on contrast medium enhancement in chest CT: a randomised controlled trial. BJR Open 2023; 5:20230054. [PMID: 37942494 PMCID: PMC10630975 DOI: 10.1259/bjro.20230054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 11/10/2023] Open
Abstract
Objective To compare a fixed-volume contrast medium (CM) protocol with a combined total body weight (TBW) and body composition-tailored protocol in chest CT. Methods and materials Patients referred for routine contrast enhanced chest CT were prospectively categorised as normal, muscular or overweight. Patients were accordingly randomised into two groups; Group 1 received a fixed CM protocol. Group 2 received CM volume according to a body composition-tailored protocol. Objective image quality comparisons between protocols and body compositions were performed. Differences between groups and correlation were analysed using t-test and Pearson's r. Results A total of 179 patients were included: 87 in Group 1 (mean age, 51 ± 17 years); and 92 in Group 2 (mean age, 52 ± 17 years). Compared to Group 2, Group 1 showed lower vascular attenuation in muscular (mean 346 Hounsfield unit (HU) vs 396 HU; p = 0.004) and overweight categories (mean 342 HU vs 367 HU; p = 0.12), while normal category patients showed increased attenuation (385 vs 367; p = 0.61). In Group 1, strongest correlation was found between attenuation and TBW in muscular (r = -.49, p = 0.009) and waist circumference in overweight patients (r = -.50, p = 0.005). In Group 2, no significant correlations were found for the same body size parameters. In Group 1, 13% of the overweight patients was below 250 HU (p = 0.053). Conclusion A combined TBW and body composition-tailored CM protocol in chest CT resulted in more homogenous enhancement and fewer outliers compared to a fixed-volume protocol. Advances in knowledge This is, to our knowledge, the first study to investigate the impact of various body compositions on contrast medium enhancement in chest CT.
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Kirsch J, Wu CC, Bolen MA, Henry TS, Rajiah PS, Brown RKJ, Galizia MS, Lee E, Rajesh F, Raptis CA, Rybicki FJ, Sams CM, Verde F, Villines TC, Wolf SJ, Yu J, Donnelly EF, Abbara S. ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update. J Am Coll Radiol 2022; 19:S488-S501. [PMID: 36436972 DOI: 10.1016/j.jacr.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Carol C Wu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Travis S Henry
- Panel Chair, Division Chief of Cardiothoracic Imaging, Duke University, Durham, North Carolina; Co-Director, ACR Education Center HRCT Course; Chair
| | | | - Richard K J Brown
- Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Elizabeth Lee
- University of Michigan Health System, Ann Arbor, Michigan; Director M1Radiology Education University of Michigan Medical School; Associated Program Director Diagnostic Radiology Michigan Medicine; Director of Residency Education Cardiothoracic Division Michigan
| | - Fnu Rajesh
- MetroHealth Medical Center, Cleveland, Ohio; Primary care physician
| | | | | | | | - Franco Verde
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Stephen J Wolf
- Denver Health, Denver, Colorado; American College of Emergency Physicians; Director of Service for Emergency Medicine, Denver Health Medical Center, Denver Colorado; Co-Chair, American College of Emergency Physicians Clinical Policies Committee
| | - Jeannie Yu
- Deputy Chief of Medicine, VA Medical Center, University of California-Irvine, Irvine, California; Society for Cardiovascular Magnetic Resonance
| | - Edwin F Donnelly
- Specialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio; Ohio State University Medical Center: Chief of Thoracic Radiology, Interim Vice Chair of Academic Affairs, Department of Radiology
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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Burghard P, Plank F, Beyer C, Müller S, Dörler J, Zaruba MM, Pölzl L, Pölzl G, Klauser A, Rauch S, Barbieri F, Langer CE, Schgoer W, Williamson EE, Feuchtner G. Evaluation of right ventricular function by coronary computed tomography angiography using a novel automated 3D right ventricle volume segmentation approach: a validation study. Eur Radiol 2018; 28:5129-5136. [PMID: 29869175 DOI: 10.1007/s00330-018-5523-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/25/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate right ventricle (RV) function by coronary computed tomography angiography (CTA) using a novel automated three-dimensional (3D) RV volume segmentation tool in comparison with clinical reference modalities. METHODS Twenty-six patients with severe end-stage heart failure [left ventricle (LV) ejection fraction (EF) <35%] referred to CTA were enrolled. A specific individually tailored biphasic contrast agent injection protocol was designed (80%/20% high/low flow) was designed. Measurement of RV function [EF, end-diastolic volume (EDV), end-systolic volume (ESV)] by CTA was compared with tricuspid annular plane systolic excursion (TAPSE) by transthoracic echocardiography (TTE) and right heart invasive catheterisation (IC). RESULTS Automated 3D RV volume segmentation was successful in 26 (100%) patients. Read-out time was 3 min 33 s (range, 1 min 50s-4 min 33s). RV EF by CTA was stronger correlated with right atrial pressure (RAP) by IC (r = -0.595; p = 0.006) but weaker with TAPSE (r = 0.366, p = 0.94). When comparing TAPSE with RAP by IC (r = -0.317, p = 0.231), a weak-to-moderate non-significant inverse correlation was found. Interobserver correlation was high with r = 0.96 (p < 0.001), r = 0.86 (p < 0.001) and r = 0.72 (p = 0.001) for RV EDV, ESV and EF, respectively. CT attenuation of the right atrium (RA) and right ventricle (RV) was 196.9 ± 75.3 and 217.5 ± 76.1 HU, respectively. CONCLUSIONS Measurement of RV function by CTA using a novel 3D volumetric segmentation tool is fast and reliable by applying a dedicated biphasic injection protocol. The RV EF from CTA is a closer surrogate of RAP than TAPSE by TTE. KEY POINTS • Evaluation of RV function by cardiac CTA by using a novel 3D volume segmentation tool is fast and reliable. • A biphasic contrast agent injection protocol ensures homogenous RV contrast attenuation. • Cardiac CT is a valuable alternative modality to CMR for the evaluation of RV function.
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Affiliation(s)
- Philipp Burghard
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria. .,, Breitenwangerstrasse 19, 6600, Reutte, Austria.
| | - Fabian Plank
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christoph Beyer
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Silvana Müller
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jakob Dörler
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Leo Pölzl
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gerhard Pölzl
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Andrea Klauser
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Stefan Rauch
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabian Barbieri
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Wilfried Schgoer
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Eric E Williamson
- Department of Radiology, Mayo Clinic Rochester, Minnesota, 200 1st St SW, Rochester, MN, 55902, USA
| | - Gudrun Feuchtner
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
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Kirsch J, Brown RKJ, Henry TS, Javidan-Nejad C, Jokerst C, Julsrud PR, Kanne JP, Kramer CM, Leipsic JA, Panchal KK, Ravenel JG, Shah AB, Mohammed TL, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 14:S2-S12. [PMID: 28473076 DOI: 10.1016/j.jacr.2017.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jacobo Kirsch
- Principal Author, Cleveland Clinic, Weston, Florida.
| | | | - Travis S Henry
- University of California San Francisco, San Francisco, California
| | - Cylen Javidan-Nejad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christopher M Kramer
- University of Virginia Health System, Charlottesville, Virginia; American College of Cardiology
| | | | | | - James G Ravenel
- Medical University of South Carolina, Charleston, South Carolina
| | - Amar B Shah
- Westchester Medical Center, Valhalla, New York
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Pamela K Woodard
- Specialty Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Suhny Abbara
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
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Role of Cardiac Computed Tomography in the Evaluation of Coronary Artery Stenosis in Patients With Ascending Aorta Aneurysm Detected at Transthoracic Echocardiography. J Comput Assist Tomogr 2017; 40:393-7. [PMID: 27192500 DOI: 10.1097/rct.0000000000000380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The aim of our study was to evaluate the diagnostic performance of cardiac computed tomography (CCT) in the evaluation of coronary artery stenosis in patients with ascending aorta aneurysm detected at transthoracic echocardiography. METHODS We conducted a retrospective analysis of patients with an aneurysm 45 mm or greater at transthoracic echocardiography who underwent CCT from 2012 to 2014 in our hospital. We calculated the sensitivity, specificity, and positive and negative predictive values of CCT for the assessment of coronary artery stenosis (<50% or ≥50% stenosis) in patients who underwent conventional coronary angiography. RESULTS We included 104 patients (73 men, aged 64 [SD, 10.8] years) in our study. Obstructive coronary artery disease was found in 22.1% of patients. Sensitivity, specificity, and positive and negative predictive values of CCT for detecting significant stenoses were 100%, 98%, and 82% and 100% on a segment-by-segment analysis and 100%, 83%, and 65% and 100% on a per-patient analysis, respectively. CONCLUSIONS Cardiac computed tomography provides a comprehensive evaluation of ascending aorta aneurysms and coronary artery tree.
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Apitzsch J, Jost G, Bonifer E, Keulers A, Pietsch H, Mahnken AH. Revival of monophasic contrast injection protocols: superiority of a monophasic injection protocol compared to a biphasic injection protocol in high-pitch CT angiography. Acta Radiol 2016; 57:1210-6. [PMID: 26663210 DOI: 10.1177/0284185115618546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 10/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Biphasic injection protocols are frequently used because they yield homogenous contrast enhancement. We hypothesize that with faster scanners and shorter scan times, biphasic injection protocols are no longer necessary. PURPOSE To evaluate whether a monophasic injection protocol is equivalent to a biphasic protocol in terms of contrast enhancement and homogeneity. MATERIAL AND METHODS Repeated high-pitch CTA (pitch 3) and conventional standard-pitch computed tomography angiography (CTA) (pitch 1.2) from the cervical region to the symphysis was performed in seven beagles (11.2 ± 2.5 kg) in a cross-over study design. Arterial contrast enhancement was measured along the z-axis in the ascending, descending, and abdominal aorta and the iliac arteries. The z-axis is the longitudinal axis of the human body and at the same time the direction in which the CT table is moving. The data were analyzed using repeated measures ANOVA with a post-hoc t-test and visual assessment of the scans. RESULTS In high-pitch CTA, monophasic injection protocols were superior to biphasic injection protocols in enhancement levels (P < 0.05) and enhancement homogeneity along the z-axis (P < 0.05). In conventional CTA, enhancement levels did not differ. Contrast homogeneity was better for biphasic protocols. CONCLUSION High-pitch CTA monophasic injection protocols are superior to biphasic injection protocols, due to a higher and more homogeneous contrast enhancement with the same amount of contrast medium used.
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Affiliation(s)
- Jonas Apitzsch
- UKGM Marburg University Hospital, Diagnostic and Interventional Radiology, Marburg, Germany
| | - Gregor Jost
- Bayer Healthcare, MR and CT Contrast Media Research, Berlin, Berlin, Germany
| | - Elisabeth Bonifer
- Department of Radiology, Giessen University Hospital, Giessen, Hessen, Germany
| | - Annika Keulers
- UKGM Marburg University Hospital, Diagnostic and Interventional Radiology, Marburg, Germany
| | - Hubertus Pietsch
- Bayer Healthcare, MR and CT Contrast Media Research, Berlin, Berlin, Germany
| | - Andreas Horst Mahnken
- UKGM Marburg University Hospital, Diagnostic and Interventional Radiology, Marburg, Germany
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Chinnaiyan KM, Raff GL. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:62. [DOI: 10.1007/s11936-016-0484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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8
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Ayaram D, Bellolio MF, Murad MH, Laack TA, Sadosty AT, Erwin PJ, Hollander JE, Montori VM, Stiell IG, Hess EP. Triple rule-out computed tomographic angiography for chest pain: a diagnostic systematic review and meta-analysis. Acad Emerg Med 2013; 20:861-71. [PMID: 24050793 DOI: 10.1111/acem.12210] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/14/2013] [Accepted: 03/17/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to compare the image quality, diagnostic accuracy, radiation exposure, and contrast volume of "triple rule-out" (TRO) computed tomography (CT) to other diagnostic modalities commonly used to evaluate patients with nontraumatic chest pain (dedicated coronary, pulmonary embolism [PE], and aortic dissection CT; invasive coronary angiography; and nuclear stress testing). METHODS Four electronic databases were searched, along with reference lists and contacted content experts, for relevant studies from inception until October 2012. Eligible studies enrolled patients with nontraumatic chest pain, shortness of breath, suspected acute coronary syndrome (ACS), PE, or aortic dissection; used at least 64-slice CT technology; and compared TRO CT to another diagnostic modality. RESULTS Eleven studies enrolling 3,539 patients (791 TRO and 2,748 non-TRO) were included (one randomized controlled trial and 10 observational). There was no significant difference in image quality between TRO and dedicated CT scans. TRO CT had the following pooled diagnostic accuracy estimates for coronary artery disease: sensitivity of 94.3% (95% confidence interval [CI] = 89.1% to 97.5%), specificity of 97.4% (95% CI = 96.1% to 98.4%), positive likelihood ratio (LR+) of 17.71 (95% CI = 3.92 to 79.96), and negative likelihood ratio (LR-) of 0.08 (95% CI = 0.02 to 0.27). There were insufficient numbers of patients with PE or aortic dissection to generate diagnostic accuracy estimates for these conditions. Use of TRO CT involved greater radiation exposure (mean difference [MD] = 4.84 mSv, 95% CI = 1.65 to 8.04 mSv) and contrast exposure (MD = 38.0 mL, 95% CI = 28.1 to 48.0 mL) compared to non-TRO CT patients. CONCLUSIONS Triple rule-out CT is highly accurate for detecting coronary artery disease. Given the low (<1%) prevalence of PE and aortic dissection in the included studies, and the increased radiation and contrast exposure, there are insufficient data to recommend use of TRO CT in the diagnosis of these conditions.
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Affiliation(s)
- David Ayaram
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - M. Hassan Murad
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
- The Department of Internal Medicine; Division of Preventive Medicine; Mayo Clinic; Rochester MN
| | - Torrey A. Laack
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - Annie T. Sadosty
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
| | - Patricia J. Erwin
- The Mayo Medical Libraries; Mayo Clinic College of Medicine; Rochester MN
| | - Judd E. Hollander
- The Department of Emergency Medicine; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Victor M. Montori
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
- The Department of Internal Medicine; Division of Endocrinology and Metabolism; Mayo Clinic; Rochester MN
| | - Ian G. Stiell
- The Department of Emergency Medicine and Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Erik P. Hess
- Department of Emergency Medicine; Division of Emergency Medicine Research; Mayo Clinic; Rochester MN
- The Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
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Bilolikar AN, Chinnaiyan KM. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Cardiac CT for the assessment of chest pain: Imaging techniques and clinical results. Eur J Radiol 2012; 81:3675-9. [DOI: 10.1016/j.ejrad.2011.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 05/13/2011] [Indexed: 02/06/2023]
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Ley S, Ley-Zaporozhan J, Pitton MB, Schneider J, Wirth GM, Mayer E, Düber C, Kreitner KF. Diagnostic performance of state-of-the-art imaging techniques for morphological assessment of vascular abnormalities in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 2011; 22:607-16. [DOI: 10.1007/s00330-011-2290-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/24/2011] [Accepted: 09/12/2011] [Indexed: 11/30/2022]
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Madder RD, Raff GL, Hickman L, Foster NJ, McMurray MD, Carlyle LM, Boura JA, Chinnaiyan KM. Comparative diagnostic yield and 3-month outcomes of "triple rule-out" and standard protocol coronary CT angiography in the evaluation of acute chest pain. J Cardiovasc Comput Tomogr 2011; 5:165-71. [PMID: 21511557 DOI: 10.1016/j.jcct.2011.03.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 02/12/2011] [Accepted: 03/09/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND "Triple rule-out" CT angiography simultaneously evaluates coronary artery disease, pulmonary embolism, and aortic dissection in a single imaging examination. However, the clinical outcomes of this approach are unknown. OBJECTIVE Using standard cardiac CT angiography as a reference, this study was performed to describe the diagnostic yield and clinical outcomes of patients undergoing triple rule-out in clinical practice. METHODS We identified consecutive patients at 2 institutions undergoing triple rule-out or cardiac CT angiography for acute chest pain. The primary outcome was a composite diagnostic yield consisting of coronary artery diameter stenosis >50%, pulmonary embolism, and aortic dissection. Other reported outcomes included radiation dose, downstream resource use, and 90-day clinical outcomes. RESULTS Among 2068 patients (272 triple rule-out and 1796 cardiac CT angiograms), the composite diagnostic yield was 14.3% with triple rule-out and 16.3% with cardiac CT (P = 0.41) and was driven by the diagnosis of obstructive coronary artery disease (13.2% triple rule-out versus 16.1% cardiac CT, P = 0.22). The diagnostic yield for pulmonary embolism was low (1.1% triple rule-out and 0.2% cardiac CT, P = 0.052) and no aortic dissections were found in either group. Compared with cardiac CT, the triple rule-out approach was associated with higher radiation exposure (12.0 ± 5.6 mSv versus 8.2 ± 4.0 mSv, P < 0.0001), a greater incidence of subsequent emergency center cardiac evaluations (5.9% versus 2.5%, P = 0.0017), and more downstream pulmonary embolism-protocol CT angiography (3.3% versus 0.9%, P = 0.0034). CONCLUSIONS Among patients with acute chest pain, a triple rule-out approach resulted in higher radiation exposure compared with cardiac CT, but was not associated with improved diagnostic yield, reduced clinical events, or diminished downstream resource use.
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Affiliation(s)
- Ryan D Madder
- Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073, USA.
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Coronary CT Angiography in Acute Chest Pain Syndromes. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Atalay MK, Haji-Momenian S, Grand DJ. Three Contrast Injection Protocols for Electrocardiogram-Gated 64-Slice Computed Tomographic Angiography. J Comput Assist Tomogr 2010; 34:660-5. [DOI: 10.1097/rct.0b013e3181e40793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Contrast enhanced CT-scans are not comparable to non-enhanced scans in emphysema quantification. Eur J Radiol 2010; 74:473-8. [DOI: 10.1016/j.ejrad.2009.03.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 01/30/2009] [Accepted: 03/12/2009] [Indexed: 11/18/2022]
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Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology 2009; 252:332-45. [PMID: 19703877 DOI: 10.1148/radiol.2522082335] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Triple-rule-out (TRO) computed tomographic (CT) angiography can provide a cost-effective evaluation of the coronary arteries, aorta, pulmonary arteries, and adjacent intrathoracic structures for the patient with acute chest pain. TRO CT is most appropriate for the patient who is judged to be at low to intermediate risk for acute coronary syndrome (ACS) and whose symptoms may also be attributed to acute pathologic conditions of the aorta or pulmonary arteries. Although a regular cardiac rhythm remains an important factor in coronary CT image quality, newer CT scanners with 64 or more detector rows afford rapid electrocardiographically (ECG) gated imaging to provide high-quality TRO CT studies in patients with a heart rate of up to 80 beats per minute. Injection of iodinated contrast material (< or = 100 mL) is tailored to provide simultaneous high levels of arterial enhancement in the coronary arteries and aorta (> 300 HU) and in the pulmonary arteries (> 200 HU). To limit radiation exposure, the TRO CT examination does not include the entire chest but is constrained to incorporate the aortic arch down through the heart. Scanning parameters, including prospective ECG tube current modulation and prospective ECG gating with the "step-and-shoot" technique, are tailored to reduce radiation exposure (optimally, 5-9 mSv). When performed with appropriate attention to timing and technique, TRO CT provides coronary image quality equal to that of dedicated coronary CT angiography and pulmonary arterial images that are free of motion artifact related to cardiac pulsation. In an appropriately selected emergency department patient population, TRO CT can safely eliminate the need for further diagnostic testing in over 75% of patients.
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Affiliation(s)
- Ethan J Halpern
- Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, PA 19107-5244, USA.
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Halpern EJ, Levin DC, Zhang S, Takakuwa KM. Comparison of image quality and arterial enhancement with a dedicated coronary CTA protocol versus a triple rule-out coronary CTA protocol. Acad Radiol 2009; 16:1039-48. [PMID: 19523852 DOI: 10.1016/j.acra.2009.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 03/16/2009] [Accepted: 03/16/2009] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES To compare the image quality of dedicated coronary computed tomography angiography (cCTA) to that of triple rule-out (TRO) CTA designed to evaluate the coronary arteries, thoracic aorta, and pulmonary arteries. MATERIALS AND METHODS Consecutive cCTA examinations performed by a single radiologist over 1 year were reviewed. Biphasic injection protocols were employed: 70 mL of optiray-350 followed by 40 mL of saline injected at 5.5 mL/second for dedicated cCTA; 70 mL of optiray-350 followed by 25 mL of the contrast diluted with 25 mL of saline injected at 5.0 mL/second for TRO-CTA. Two independent cardiovascular radiologists reviewed the coronary vessels in each case and rated diagnostic image quality on a 5 point scale (1, suboptimal; 3, adequate; 5, excellent). Vascular enhancement was measured in the coronary arteries, aorta, and pulmonary arteries. RESULTS There was excellent interobserver agreement between the cardiovascular radiologists (kappa = 0.91). Coronary image quality score were similar among 260 dedicated cCTA studies and 168 TRO-CTA studies (mean: 3.8-3.9. P > .18). At least one coronary segment demonstrated suboptimal image quality in 8% of examinations, including 18 dedicated cCTA studies and 16 TRO studies (P = .94). Enhancement was greater in the distal thoracic aorta of TRO patients (336 vs. 311 Hounsfield units; P = .01); no other significant differences in enhancement were identified in the aorta and coronary arteries of dedicated cCTA and TRO studies. Vascular enhancement was adequate for diagnostic evaluation of the pulmonary arteries in all TRO studies. CONCLUSIONS A TRO-CTA protocol using 95 mL of contrast can provide comparable coronary image quality and coronary vascular enhancement as compared to dedicated cCTA with 70 mL of contrast.
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Affiliation(s)
- Ethan J Halpern
- Department of Radiology, Thomas Jefferson University Hospital, 132 South 10th Street, Philadelphia, PA 19107-5244, USA.
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Hein PA, Romano VC, Lembcke A, May J, Rogalla P. Initial experience with a chest pain protocol using 320-slice volume MDCT. Eur Radiol 2009; 19:1148-55. [PMID: 19137311 DOI: 10.1007/s00330-008-1255-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 11/24/2008] [Indexed: 10/21/2022]
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Alexander SA, Rubin GD. Imaging the thoracic aorta: anatomy, technical considerations, and trauma. Semin Roentgenol 2008; 44:8-15. [PMID: 19064068 DOI: 10.1053/j.ro.2008.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Scott A Alexander
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
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Triple rule-out CT coronary angiography: three of a kind? Int J Cardiovasc Imaging 2008; 25:327-30. [PMID: 19002601 DOI: 10.1007/s10554-008-9381-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 10/20/2008] [Indexed: 10/21/2022]
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