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Cheng TW, Doros G, Jones DW, Vazirani A, Malikova MA. Evaluation of Computerized Tomography Utilization in Comparison to Digital Subtraction Angiography in Patients with Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00165-1. [PMID: 38582215 DOI: 10.1016/j.avsg.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 02/28/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Perform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography enhanced the assessment of vessel calcification, percentage of stenosis, and affected outcomes in patients with PAD. METHODS The study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n = 20), and controls who underwent angiography only (n = 19). Baseline characteristics, imaging results, and clinical outcomes were analyzed. RESULTS Thirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g., vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by computed tomography (CT) scan versus 30% by angiography (P = 0.009). For superficial femoral artery stenosis, the percentage determined by CT was 48.68% vs. 81.41% by angiography, and observed difference between 2 modalities was statistically significant (P = 0.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% vs. 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P = 0.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had reinterventions within 12 months. CONCLUSIONS Both imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g., iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during preoperative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.
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Affiliation(s)
- Thomas Wei Cheng
- Vascular Surgery Residency Program, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, Boston, MA
| | | | - Aniket Vazirani
- General Surgery Residency Program, Jefferson Abington Hospital, Philadelphia, PA
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Wang X, Nai YH, Gan J, Lian CPL, Ryan FK, Tan FSL, Chan DYS, Ng JJ, Lo ZJ, Chong TT, Hausenloy DJ. Multi-Modality Imaging of Atheromatous Plaques in Peripheral Arterial Disease: Integrating Molecular and Imaging Markers. Int J Mol Sci 2023; 24:11123. [PMID: 37446302 DOI: 10.3390/ijms241311123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/14/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral artery disease (PAD) is a common and debilitating condition characterized by the narrowing of the limb arteries, primarily due to atherosclerosis. Non-invasive multi-modality imaging approaches using computed tomography (CT), magnetic resonance imaging (MRI), and nuclear imaging have emerged as valuable tools for assessing PAD atheromatous plaques and vessel walls. This review provides an overview of these different imaging techniques, their advantages, limitations, and recent advancements. In addition, this review highlights the importance of molecular markers, including those related to inflammation, endothelial dysfunction, and oxidative stress, in PAD pathophysiology. The potential of integrating molecular and imaging markers for an improved understanding of PAD is also discussed. Despite the promise of this integrative approach, there remain several challenges, including technical limitations in imaging modalities and the need for novel molecular marker discovery and validation. Addressing these challenges and embracing future directions in the field will be essential for maximizing the potential of molecular and imaging markers for improving PAD patient outcomes.
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Affiliation(s)
- Xiaomeng Wang
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
| | - Ying-Hwey Nai
- Clinical Imaging Research Centre, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Julian Gan
- Siemens Healthineers, Singapore 348615, Singapore
| | - Cheryl Pei Ling Lian
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Fraser Kirwan Ryan
- Infocomm Technology Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Forest Su Lim Tan
- Infocomm Technology Cluster, Singapore Institute of Technology, Singapore 138683, Singapore
| | - Dexter Yak Seng Chan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
| | - Jun Jie Ng
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of Surgery, Woodlands Health, Singapore 258499, Singapore
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore 168752, Singapore
- Surgical Academic Clinical Programme, Singapore General Hospital, Singapore 169608, Singapore
- Vascular SingHealth Duke-NUS Disease Centre, Singapore 168752, Singapore
| | - Derek John Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore 169609, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore 117597, Singapore
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
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Gupta S, Dixit R, Prakash A, Daga MK, Mishra A. Can Sublingual Nitrate Improve Visualization of Lower Limb Arteries on Computed Tomography Angiography? J Comput Assist Tomogr 2023:00004728-990000000-00152. [PMID: 36877793 DOI: 10.1097/rct.0000000000001446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVE The aim of the study is to evaluate the role of sublingual nitrate in improving vessel visualization on peripheral computed tomography angiography (CTA). METHODS Fifty patients clinically diagnosed with peripheral arterial disease of the lower limb were prospectively included in this study: Twenty-five underwent CTA after sublingual nitrate administration (nitrate group) and 25 without (non-nitrate group). Two blinded observers qualitatively and quantitatively assessed the data thus generated. The mean luminal diameter, intraluminal attenuation, site, and percentage of stenosis were evaluated in all segments. Assessment of collateral visualization at sites of significant stenosis was also done. RESULTS Patients in the nitrate and non-nitrate groups were similar in age and sex characteristics (P > 0.05).On subjective evaluation, there was significantly improved visualization of the femoropopliteal and tibioperoneal vasculature of the lower limb in the nitrate group compared with the non-nitrate group (P < 0.05). Quantitative evaluation showed a statistically significant difference in the measured arterial diameters for all evaluated segments in the nitrate group versus the non-nitrate group (P < 0.05). Intra-arterial attenuation was significantly greater for all segments in the nitrate group resulting in better contrast opacification in these studies. Collateral visualization around segments with more than 50% stenosis/occlusion was also better in the nitrate group. CONCLUSIONS Our study suggests that nitrate administration before peripheral vascular CTA can improve visualization, especially in the distal segments by increasing the vessel diameter and intraluminal attenuation along with better delineation of the collateral circulation around stenotic areas. It may also improve the number of evaluable segments of vasculature in these angiographic studies.
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Affiliation(s)
- Sanchita Gupta
- From the Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India
| | - Rashmi Dixit
- From the Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India
| | - Anjali Prakash
- From the Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India
| | - Mradul Kumar Daga
- Department of Internal Medicine and Infectious disease, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anurag Mishra
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
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Cholok D, Saberski E, Lowenberg DW. Approach to Complex Lower Extremity Reconstruction. Semin Plast Surg 2022; 36:233-242. [PMID: 36561427 PMCID: PMC9762997 DOI: 10.1055/s-0042-1758205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.
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Affiliation(s)
- David Cholok
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Ean Saberski
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David W. Lowenberg
- Department of Orthopedic Surgery, Stanford University School of Medicine, Palo Alto, California
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Byeon JY, Kwak SH, Choi HJ, Kim JH, Lee DW. Clinical significance of early venous enhancement on CT angiography of the ischemic lower limbs. Medicine (Baltimore) 2022; 101:e30560. [PMID: 36181004 PMCID: PMC9524914 DOI: 10.1097/md.0000000000030560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.
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Affiliation(s)
- Je Yeon Byeon
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, Korea
- * Correspondence: Hwan Jun Choi, Department of Plastic & Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Bongmyeong-dong, Dongnam-gu, Cheonan-si, Chungcheongnam-do 330-721, Korea (e-mail: )
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Da Woon Lee
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Shwaiki O, Rashwan B, Fink MA, Kirksey L, Gadani S, Karuppasamy K, Melzig C, Thompson D, D'Amico G, Rengier F, Partovi S. Lower extremity CT angiography in peripheral arterial disease: from the established approach to evolving technical developments. Int J Cardiovasc Imaging 2021; 37:3101-3114. [PMID: 33997924 DOI: 10.1007/s10554-021-02277-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
With the advent of multidetector computed tomography (CT), CT angiography (CTA) has gained widespread popularity for noninvasive imaging of the arterial vasculature. Peripheral extremity CTA can nowadays be performed rapidly with high spatial resolution and a decreased amount of both intravenous contrast and radiation exposure. In patients with peripheral artery disease (PAD), this technique can be used to delineate the bilateral lower extremity arterial tree and to determine the amount of atherosclerotic disease while differentiating between acute and chronic changes. This article provides an overview of several imaging techniques for PAD, specifically discusses the use of peripheral extremity CTA in patients with PAD, clinical indications, established technical considerations and novel technical developments, and the effect of postprocessing imaging techniques and structured reporting.
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Affiliation(s)
- Omar Shwaiki
- Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Basem Rashwan
- Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Matthias A Fink
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Levester Kirksey
- Department of Vascular Surgery, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sameer Gadani
- Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | | | - Claudius Melzig
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dustin Thompson
- Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Giuseppe D'Amico
- Department of Transplant Surgery, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Fabian Rengier
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sasan Partovi
- Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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Qu TT, Li J, Ding NN, Zhou L, Guo J, Li Y, Liu Z, Han Y, Cui Y, Yang J. Differentiating total from subtotal arterial occlusion in lower extremities by using reverse attenuation gradient sign in CT angiography. Eur Radiol 2021; 31:8335-8341. [PMID: 33890150 DOI: 10.1007/s00330-021-07929-3] [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: 11/16/2020] [Revised: 02/07/2021] [Accepted: 03/23/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate the use of reverse attenuation gradient sign (RAGS) in CT angiography (CTA) to differentiate total from subtotal occlusion in lower extremities which poses different challenges for the procedure and carries different prognoses. METHODS Eighty patients with 91 lesions in the lower extremities were divided into total occlusion (TO) group and subtotal occlusion (SO) group confirmed by digital subtraction angiography. The CT numbers of vascular lumen at the end of lesion (proximal, P) and at the first entrance (distal, D) of the lateral branch were measured and their difference (CT(PD) = CT(P) - CT(D)) of each lesion was calculated. The CT number gradient (G(DP) = 2 * CT(PD)/[CT(P) + CT(D)]) was calculated by dividing the CT number difference by the average CT number of the two points. The existence of RAGS where the CT number at the distal point is higher than that at the proximal point (CT(PD) and G(PD) < 0) was determined and the diagnostic efficacy of using RAGS in CTA for differentiating total from subtotal occlusive lesions in lower extremities was calculated. RESULTS The SO group had higher CT numbers than the TO group (p < 0.001). More importantly, the SO group had positive CT number gradient (G(PD) > 0), while the gradient was negative (G(PD) < 0) in the TO group. The specificity and sensitivity of using RAGS (G(PD) < 0) in images for diagnosing TO of lower extremity were 97.6% and 92.0%, respectively, and 87.8% and 88.0% using the standard CTA images. CONCLUSION The use of RAGS in CTA images has high diagnostic accuracy to differentiate TO from SO in lower extremities. KEY POINTS • Total occlusions often exhibit higher CT number at distal point than at proximal point to the occlusion. • The reverse attenuation gradient sign (RAGS) may be determined using the CT number measurements between the proximal and distal points after occlusion. • RAGS can be used to improve the diagnostic efficiency in CTA to differentiate between total and subtotal occlusions of lower extremity arteries.
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Affiliation(s)
- Ting-Ting Qu
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Jianying Li
- CT Research Center, GE Healthcare China, Beijing, 100176, People's Republic of China
| | - Ning-Ning Ding
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Li Zhou
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Jianxin Guo
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Yanan Li
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Zhe Liu
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Yaqing Han
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Yuling Cui
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China
| | - Jian Yang
- Department of Radiology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi Province, People's Republic of China.
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Park S, Park SH, Hwang JH, Kim JH, Lee KH, Park SH, Shin JH, Pak SY, Kang JM. Low-dose CT angiography of the lower extremities: a comparison study of image quality and radiation dose. Clin Radiol 2020; 76:156.e19-156.e26. [PMID: 33256975 DOI: 10.1016/j.crad.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/28/2020] [Indexed: 01/22/2023]
Abstract
AIM To investigate the image quality and radiation dose of ultralow-dose (ULD) and low-dose (LD) lower-extremity computed tomography (CT) angiography (LE-CTA) using the advanced modelled iterative reconstruction (ADMIRE) algorithm to detect peripheral arterial disease (PAD) in comparison with standard-dose (SD) CT. MATERIALS AND METHODS One hundred and seven consecutive patients were examined using LE-CTA at 70 kVp and a dual-source scanner to achieve three image sets using 30% (ULD), 70% (LD), and 100% (SD) tube loads. Qualitative analysis was conducted by examining the three image sets for overall quality. The image quality of arterial segments was analysed by two independent readers. In addition, the CT dose index (CTDIvol) was measured in the three image sets. RESULTS The mean overall quality scores were 3.4±0.6 for ULD CT, 3.9±0.3 for LD CT, and 3.9±0.2 for SD CT. Both readers scored the arterial segments as 2-4 (adequate-excellent) in the three image sets. In addition, 89.4% (93/104) and 54.8% (57/104) segments of PAD with calcified plaques were scored 4 between SD and LD CT and between SD and ULD CT, respectively, and 45.2% (47/104) segments had a lower score by one point in ULD CT compared with SD CT. The mean CTDIvol was 4.1±1.1 mGy for SD CT, 2.9±0.8 mGy for LD CT, and 1.2±0.3 mGy for ULD CT. CONCLUSIONS LD/ULD CT at 70 kVp using ADMIRE reconstruction enables a reduction in the radiation dose while enabling adequate evaluation or follow-up of PAD based on LE-CTA.
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Affiliation(s)
- S Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - S H Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - J H Hwang
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea.
| | - J H Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - K H Lee
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
| | - S H Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J H Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S Y Pak
- Department of Biomedical Engineering, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J M Kang
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774beon-gil, Namdong-gu, Incheon, Republic of Korea
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Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience. Ann Plast Surg 2020; 84:425-430. [PMID: 32000250 DOI: 10.1097/sap.0000000000002227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. METHODS A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. RESULTS One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). CONCLUSIONS In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.
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Abstract
Objectives: Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center. Methods: We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied. Results: A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001). Conclusion: CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients’ treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.
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Shin T, Menon RG, Thomas RB, Cavallo AU, Sarkar R, Crawford RS, Rajagopalan S. Unenhanced Velocity-Selective MR Angiography (VS-MRA): Initial Clinical Evaluation in Patients With Peripheral Artery Disease. J Magn Reson Imaging 2019; 49:744-751. [PMID: 30211442 PMCID: PMC6375774 DOI: 10.1002/jmri.26268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/06/2018] [Accepted: 07/06/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Safe and accurate imaging of the peripheral arterial system is important for diagnosis and treatment planning of patients with peripheral artery disease (PAD). PURPOSE To evaluate image quality and diagnostic performance of unenhanced magnetic resonance angiography (MRA) based on velocity-selective (VS) magnetization preparation (termed VS-MRA). STUDY TYPE Prospective. POPULATION Thirty-one symptomatic PAD patients underwent VS-MRA. Twenty-four of them underwent clinical digital subtraction angiography (DSA) examination, 18.8 ± 5.2 days after the MR scans. FIELD STRENGTH/SEQUENCE 1.5T MRI that included VS-MRA (homemade research sequence) and phase-contrast flow imaging (clinical sequence). ASSESSMENT Image quality (0: nondiagnostic, 3: excellent) and stenosis severity (0: normal, 3: occlusion) of VS-MRA images were assessed independently by three reviewers. Arterial signal-to-noise-ratio (SNR) and artery-to-muscle contrast-to-noise ratio (CNR) were calculated. STATISTICAL TESTS The sensitivity and specificity of VS-MRA were calculated for the detection of significant stenosis (>50%) with DSA as the reference standard. Interobserver agreement among the three reviewers was evaluated by using Cohen κ-statistics. RESULTS The image quality score of VS-MRA was 2.7 ± 0.5 for Reader 1, 2.8 ± 0.5 for Reader 2, and 2.8 ± 0.4 for Reader 3; SNR and CNR were 37.8 ± 12.5 and 30.5 ± 11.8, respectively. Segment-based analysis revealed that VS-MRA had sensitivities of 85.3%, 74.5%, and 78.4%, respectively, for the three reviewers, and specificities of 93.5%, 96.8%, and 95.2%. The interobserver agreement for the stenosis grading was good, as demonstrated by Cohen κ values of 0.76 (Reader 1 vs. Reader 2), 0.82 (Reader 1 vs. Reader 3), and 0.79 (Reader 2 vs. Reader 3). DATA CONCLUSION Unenhanced VS-MRA allows clear depiction of the peripheral arteries and accurate stenosis grading, as evidenced by high image quality scores and strong agreement with DSA. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:744-751.
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Affiliation(s)
- Taehoon Shin
- Division of Mechanical and Biomedical Engineering, Ewha Womans University, Seoul, South Korea
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, Maryland
| | - Rajiv G. Menon
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, Maryland
- Department of Radiology, New York University, New York, New York
| | - Rahul B. Thomas
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Armando U. Cavallo
- Diagnostic and Interventional Radiology Division, University Hospital Policlinico “Tor Vergata”, Rome, Italy
| | - Rajabraka Sarkar
- Division of Vascular and Endovascular Surgery, University of Maryland, Baltimore, Maryland
| | - Robert S. Crawford
- Division of Vascular and Endovascular Surgery, University of Maryland, Baltimore, Maryland
| | - Sanjay Rajagopalan
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
- Division of Cardiovascular Medicine, University of Maryland, Baltimore, Maryland
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Caruso D, Parinella AH, Schoepf UJ, Stroebel MH, Mangold S, Wichmann JL, Varga-Szemes A, Ball BD, De Santis D, Laghi A, De Cecco CN. Optimization of window settings for standard and advanced virtual monoenergetic imaging in abdominal dual-energy CT angiography. Abdom Radiol (NY) 2017; 42:772-780. [PMID: 27878637 DOI: 10.1007/s00261-016-0963-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine the optimal window setting for displaying virtual monoenergetic reconstructions of third generation dual-source, dual-energy CT (DECT) angiography of the abdomen. METHODS Forty-five patients were evaluated with DECT angiography (90/150 kV, 180/90 ref. mAs). Three datasets were reconstructed: standard linear blending (M_0.6), 70 keV traditional virtual monoenergetic (M70), and 40 keV advanced noise-optimized virtual monoenergetic (M40+). The best window setting (width and level, W/L) was assessed by two blinded observers and was correlated with aortic attenuation to obtain the Optimized W/L setting (O-W/L). Subjective image quality was assessed, and vessel diameters were measured to determine any possible influences between different W/L settings. Repeated measures of variance were used to evaluate comparison of W/L values, image quality, and vessel sizing between M_0.6, M70, and M40+. RESULTS The Best W/L (B-W/L) for M70 and M40+ was 880/280 and 1410/450, respectively. Results from regression analysis inferred an O-W/L of 850/270 for M70 and 1350/430 for M40+. Significant differences for W and L were found between the Best and the Optimized W/L for M40+, and between M70 and M40+ for both the Best and Optimized W/L. No significant differences for vessel measurements were found using the O-W/L for M40+ compared to the standard M_0.6 (p ≥ 0.16), and significant differences were observed when using the B-W/L with M40+ compared to M_0.6 (p ≤ 0.04). CONCLUSION In order to optimize virtual monoenergetic imaging with both traditional M70 and advanced M40+, adjusting the W/L settings is necessary. Our results suggest a W/L setting of 850/270 for M70 and 1350/430 for M40+.
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Affiliation(s)
- Damiano Caruso
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
- Department of Radiological Sciences, Oncological and Pathological Sciences, University of Rome "Sapienza", Latina, Italy
| | - Ashley H Parinella
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
| | - U Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA.
- Division of Cardiology, Department of MedicineMedical, University of South Carolina, Charleston, SC, USA.
| | - Maxwell H Stroebel
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
| | - Stefanie Mangold
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls University Tuebingen, Tuebingen, Germany
| | - Julian L Wichmann
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
| | - B Devon Ball
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
| | - Domenico De Santis
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
- Department of Radiological Sciences, Oncological and Pathological Sciences, University of Rome "Sapienza", Latina, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncological and Pathological Sciences, University of Rome "Sapienza", Latina, Italy
| | - Carlo N De Cecco
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Drive, Charleston, SC, 29425, USA
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Hingorani A, Ascher E, Marks N, Mutyala M, Shiferson A, Flyer M, Jacob T. Comparison of Computed Tomography Angiography to Contrast Arteriography for Patients Undergoing Evaluation for Lower Extremity Revascularization. Vasc Endovascular Surg 2016; 41:115-9. [PMID: 17463200 DOI: 10.1177/1538574406297265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In an effort to explore alternatives to contrast arteriography, we compared computed tomography angiography to contrast arteriography for defining anatomic features of patients undergoing lower extremity revascularization. From November 2003 to March 2004, 36 inpatients with chronic lower extremity ischemia underwent contrast arteriography and computed tomography angiography before undergoing lower extremity revascularization procedures. A Siemens 16 slice multiplanar computed tomography device with bolus tracking was used for these exams. The reports of these tests and images were compared prospectively, and the differences in the aorto-iliac segment, femoral-popliteal, and infrapopliteal segments were noted. The vessels were classified as mild disease (<50%), moderate disease (50%-70%), severe (71%-99%), and occluded. The studies and treatment plans based on these data were compared. The mean age was 76 ± 12 years (SD). Indications for the procedures included gangrene (45%), ischemic ulcer (32%), rest pain (19%), and severe claudication (3%); 69% were diabetics. Accuracy of computed tomography angiography in the aorto-iliac, femoral-popliteal, and infrapopliteal segments was 100%, 81%, and 59%, respectively. Thirteen of 18 (72%) of these disagreements resulted in a different procedure than that suggested by computed tomography angiography. A review of the data obtained in this series indicated that computed tomography angiography appears to be unable to obtain adequate information in this highly selected population at our institution.
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Affiliation(s)
- Anil Hingorani
- Division of Vascular Surgery, Department of Surgery, Mainmonides Medcine Center, Brooklyn, New York 11219, USA
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Clinical indications for CT angiography in lower extremity trauma. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Low-Voltage, High-Pitch Computerized Tomography Angiography of the Infrarenal Aorta and Lower Extremity Vessels: Assessment of Radiation Dose, Image Quality With Hybrid Iterative Reconstruction, and Efficacy of Test Injection Using a Monitoring Scan at Knee Level. J Comput Assist Tomogr 2016; 40:402-8. [PMID: 26854413 DOI: 10.1097/rct.0000000000000365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our aim was to assess image quality and radiation dose of low-voltage high-pitch computed tomography angiography of the infrarenal aorta and lower extremities and evaluate the efficacy of test injection technique using a monitoring scan at knee level. METHODS A total of 60 patients with suspected peripheral arterial disease were divided into 2 groups: group 1 (30 patients, 80 kVp, high pitch [3.2], and hybrid iterative reconstruction [sinogram-affirmed iterative reconstruction]) and group 2 (30 patients, 120 kVp, low pitch [1.0], and filtered back projection reconstruction). The test injection technique at knee level was used to determine the scan delay time in group 1. The image quality and radiation exposure were compared. RESULTS There were significant differences between the 2 groups in mean (SD) arterial attenuation (80 vs 120 kVp: 507.78 [103.01] vs 317.54 [62.03] Hounsfield units, P < 0.001), mean (SD) signal-to-noise ratio (51.04 [20.29] vs 34.66 [9.94], P < 0.001), and contrast-to-noise ratio (44.83 [17.93] vs 28.26 [9.60], P < 0.001). No difference in subjective image quality was found between the 2 groups (all P > 0.05). The imaging time was significantly shorter in group 1 (2.70 [0.11] vs 14.65 [0.90s], P < 0.001). The mean (SD) effective dose was significantly lower in the 80 kVp group (0.76 [0.06] vs 4.29 [0.63] mSv, P < 0.001). CONCLUSIONS The 80-kVp high-pitch computed tomography angiography of the lower limbs using sinogram-affirmed iterative reconstruction yields reduction of radiation exposure as well as obtains acceptable image quality if acquisition protocols are used in conjunction with the test injection technique using monitoring scan at knee level to determine the delay time.
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Oztekin PS, Ergun E, Cıvgın E, Yigit H, Kosar PN. Variants of the popliteal artery terminal branches as detected by multidetector ct angiography. Open Med (Wars) 2015; 10:483-491. [PMID: 28352741 PMCID: PMC5368887 DOI: 10.1515/med-2015-0056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/15/2015] [Indexed: 12/05/2022] Open
Abstract
Objective To evaluate variants of the popliteal artery (PA) terminal branches with 64-multidetector computed tomographic angiography (64-MD CTA). Materials and Methods A total of 495 extremities (251 right, 244 left) of 253 patients undergoing a 64-MD CTA examination were included in the study. Of these, 242 extremities were evaluated bilaterally, whereas 11 were evaluated unilaterally. The terminal branching pattern of the PA was classified according to the classification scheme proposed by Kim; the distance between the medial tibial plateau and the origin of the anterior tibial artery (A) and the length of the tibioperoneal trunk (B) have been measured and recorded. Results In 459 cases (92.7%) branching of PA occurred distal to the knee joint (Type I); in 18 cases (2.8%) PA branching was superior to the knee joint (Type II); and hypoplasia of the PA branches was found in 27 cases (5.5%) (Type III). Among these types the most frequent branching patterns were Type IA (87.5%), Type IIIA (3.9%), and Type IB (3.8%). The ranges of A and B mean distances were 47.6 mm and 29.6 mm, respectively Conclusion Variations in popliteal artery terminal branching pattern occurred in 7.4% to 17.6% of patients. Pre-surgical detection of these variations with MD CTA may help to reduce the risk of iatrogenic arterial injury by enabling a better surgical treatment plan.
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Affiliation(s)
- Pelin Seher Oztekin
- Ankara Training and Research Hospital Radiology Department, Ankara, Turkey , Department of Radiology, Ankara Training and Research Hospital (SB Ankara Eğitim ve Araştırma Hastanesi), Şükriye Mh. Ulucanlar Cd. No:89, 06340 Cebeci/ Ankara, Turkey
| | - Elif Ergun
- Ankara Training and Research Hospital Radiology Department, Turkey
| | - Esra Cıvgın
- Ankara Training and Research Hospital Radiology Department, Turkey
| | - Hasan Yigit
- Ankara Training and Research Hospital Radiology Department, Turkey
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Differential Diagnosis of Chronic Total Occlusive and Subtotal Occlusive Disease of the Lower Extremity Arteries Using Reverse Attenuation Gradient Sign on CT Angiography. AJR Am J Roentgenol 2015; 205:W550-5. [DOI: 10.2214/ajr.14.14251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Xie D, Na J, Zhang M, Dong S, Xiao X. CT angiography of the lower extremity and coronary arteries using 256-section CT: a preliminary study. Clin Radiol 2015; 70:1281-8. [PMID: 26275584 DOI: 10.1016/j.crad.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 05/18/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
AIM To investigate the possible use of a 256-section computed tomography (CT) prospective electrocardiography (ECG)-gated wide volume scanning protocol for combined angiography of the lower extremity and coronary arteries, after a single injection of contrast medium, in patients with lower extremity peripheral arterial disease (PAD). MATERIALS AND METHODS Thirty-four patients with suspected PAD underwent CT angiography (CTA) with a prospective ECG-gated protocol that covered the level of the tracheal bifurcation to the foot sole. Digital subtraction angiography (DSA) of the lower extremity arteries was performed on patients requiring therapeutic intervention. Image quality and stenosis of the coronary and lower extremity arteries were assessed. RESULTS A total of 93.1% of the coronary segments were adequate for diagnosis. 17 (50%) patients showed coronary artery stenosis ≥50%. A total of 95.8% of the lower extremity arterial segments were adequate for diagnosis. Twenty-eight patients with severe lower extremity arterial stenosis or occlusion underwent DSA. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CTA for the detection of significant lower arterial stenosis (≥50%) was 94.8%, 97.2%, 95.3%, 96.9%, and 96.3%, respectively. CONCLUSION Using the prospective ECG-gated wide volume CTA protocol, images of the coronary and lower extremity arteries suitable for diagnosis can be acquired simultaneously after a single injection of contrast agent. In addition to accurately diagnosing PAD, combined angiography may be used to screen for coronary heart disease in patients with PAD.
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Affiliation(s)
- D Xie
- Department of Computer Tomography, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - J Na
- Department of MRI, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - M Zhang
- Department of Computer Tomography, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - S Dong
- Department of Computer Tomography, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - X Xiao
- Department of Computer Tomography, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China.
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Kim YH, Bae JI, Jeon YS, Kim CW, Jae HJ, Park KB, Cho YK, Kim MD. Korean Guidelines for Interventional Recanalization of Lower Extremity Arteries. Korean J Radiol 2015; 16:696-722. [PMID: 26175569 PMCID: PMC4499534 DOI: 10.3348/kjr.2015.16.4.696] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/21/2015] [Indexed: 12/20/2022] Open
Abstract
Peripheral arterial occlusive disease caused by atherosclerosis can present with intermittent claudication or critical limb ischemia. Proper diagnosis and management is warranted to improve symptoms and salvage limbs. With the introduction of new techniques and dedicated materials, endovascular recanalization is widely performed for the treatment of peripheral arterial occlusive disease because it is less invasive than surgery. However, there are various opinions regarding the appropriate indications and procedure methods for interventional recanalization according to operator and institution in Korea. Therefore, we intend to provide evidence based guidelines for interventional recanalization by multidisciplinary consensus. These guidelines are the result of a close collaboration between physicians from many different areas of expertise including interventional radiology, interventional cardiology, and vascular surgery. The goal of these guidelines is to ensure better treatment, to serve as a guide to the clinician, and consequently, to contribute to public health care.
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Affiliation(s)
- Young Hwan Kim
- Department of Radiology, Keimyung University College of Medicine, Daegu 700-712, Korea
| | - Jae Ik Bae
- Mint Radiologic Clinic, Seongnam 463-950, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University College of Medicine, Incheon 400-711, Korea
| | - Chang Won Kim
- Department of Radiology, Pusan National University College of Medicine, Busan 602-739, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University College of Medicine, Seoul 110-744, Korea
| | - Kwang Bo Park
- Department of Radiology, Sungkyunkwan University College of Medicine, Seoul 135-710, Korea
| | - Young Kwon Cho
- Department of Radiology, Eulji University College of Medicine, Seoul 139-872, Korea
| | - Man Deuk Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul 120-752, Korea
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Schernthaner RE, Wolf F, Mistelbauer G, Weber M, Sramek M, Groeller E, Loewe C. New hybrid reformations of peripheral CT angiography: do we still need axial images? Clin Imaging 2015; 39:603-7. [PMID: 25825345 DOI: 10.1016/j.clinimag.2015.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/16/2015] [Accepted: 03/10/2015] [Indexed: 01/05/2023]
Abstract
PURPOSE To quantify the detectability of peripheral artery stenosis on hybrid CT angiography (CTA) reformations. METHODS Hybrid reformations were developed by combining multipath curved planar reformations (mpCPR) and maximum intensity projections (MIP). Fifty peripheral CTAs were evaluated twice: either with MIP, mpCPR and axial images or with hybrid reformations only. Digital subtraction angiography served as gold standard. RESULTS Using hybrid reformations, two independent readers detected 88.0% and 81.3% of significant stenosis, respectively. However, CTA including axial images detected statistically significant more lesions (98%). CONCLUSION Peripheral CTA reading including axial images is still recommended. Further improvement of these hybrid reformations is necessary.
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Affiliation(s)
- Ruediger Egbert Schernthaner
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Florian Wolf
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Gabriel Mistelbauer
- Institute of Computer Graphics and Algorithms, Technical University of Vienna, Favoritenstraße 9-11, 1040 Vienna, Austria.
| | - Michael Weber
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Milos Sramek
- Commission for Scientific Visualization, Austrian Academy of Sciences, Donau-City Straße 1, 1220 Vienna, Austria.
| | - Eduard Groeller
- Institute of Computer Graphics and Algorithms, Technical University of Vienna, Favoritenstraße 9-11, 1040 Vienna, Austria.
| | - Christian Loewe
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Shen Y, Sun Z, Xu L, Li Y, Zhang N, Yan Z, Fan Z. High-pitch, low-voltage and low-iodine-concentration CT angiography of aorta: assessment of image quality and radiation dose with iterative reconstruction. PLoS One 2015; 10:e0117469. [PMID: 25643353 PMCID: PMC4314070 DOI: 10.1371/journal.pone.0117469] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/25/2014] [Indexed: 11/18/2022] Open
Abstract
Objective To assess the image quality of aorta obtained by dual-source computed tomography angiography (DSCTA), performed with high pitch, low tube voltage, and low iodine concentration contrast medium (CM) with images reconstructed using iterative reconstruction (IR). Methods One hundred patients randomly allocated to receive one of two types of CM underwent DSCTA with the electrocardiogram-triggered Flash protocol. In the low-iodine group, 50 patients received CM containing 270 mg I/mL and were scanned at low tube voltage (100 kVp). In the high-iodine CM group, 50 patients received CM containing 370 mg I/mL and were scanned at the tube voltage (120 kVp). The filtered back projection (FBP) algorithm was used for reconstruction in both groups. In addition, the IR algorithm was used in the low-iodine group. Image quality of the aorta was analyzed subjectively by a 3-point grading scale and objectively by measuring the CT attenuation in terms of the signal- and contrast-to-noise ratios (SNR and CNR, respectively). Radiation and CM doses were compared. Results The CT attenuation, subjective image quality assessment, SNR, and CNR of various aortic regions of interest did not differ significantly between two groups. In the low-iodine group, images reconstructed by FBP and IR demonstrated significant differences in image noise, SNR, and CNR (p<0.05). The low-iodine group resulted in 34.3% less radiation (4.4 ± 0.5 mSv) than the high-iodine group (6.7 ± 0.6 mSv), and 27.3% less iodine weight (20.36 ± 2.65 g) than the high-iodine group (28 ± 1.98 g). Observers exhibited excellent agreement on the aortic image quality scores (κ = 0.904). Conclusions CT images of aorta could be obtained within 2 s by using a DSCT Flash protocol with low tube voltage, IR, and low-iodine-concentration CM. Appropriate contrast enhancement was achieved while maintaining good image quality and decreasing the radiation and iodine doses.
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Affiliation(s)
- Yanguang Shen
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Department of Radiology, Hospital Affiliated to Hainan Medical College, Haikou, City of Hainan Province, China
| | - Zhonghua Sun
- Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, Perth, Australia
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yu Li
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Nan Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Zixu Yan
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Zhanming Fan
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University—Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- * E-mail:
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Rubin GD. Computed tomography: revolutionizing the practice of medicine for 40 years. Radiology 2015; 273:S45-74. [PMID: 25340438 DOI: 10.1148/radiol.14141356] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology.
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Affiliation(s)
- Geoffrey D Rubin
- From the Duke Clinical Research Institute and Department of Radiology, Duke University School of Medicine, PO Box 17969, 2400 Pratt St, Durham, NC 27715
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Garcia MJ. Computed Tomographic Angiography (CTA) of the Coronary, Aorta, Visceral, and Lower Extremity Arteries. PANVASCULAR MEDICINE 2015:1225-1248. [DOI: 10.1007/978-3-642-37078-6_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Delivering the Saline Chaser Via a Spiral Flow-Generating Tube Improves Arterial Enhancement for Computed Tomography Angiography of the Lower Extremities. J Comput Assist Tomogr 2015; 39:962-8. [PMID: 26248150 DOI: 10.1097/rct.0000000000000292] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Oca Pernas R, Delgado Sánchez-Gracián C, Tardáguila de la Fuente G, Fernández del Valle A, Silva Priegue N, González Vázquez M, Trinidad López C. Comparison of image quality and radiation dose in computed tomography angiography of the peripheral arteries using tube voltage of 80kV versus 100kV. RADIOLOGIA 2014. [DOI: 10.1016/j.rxeng.2012.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Saltybaeva N, Jafari ME, Hupfer M, Kalender WA. Estimates of Effective Dose for CT Scans of the Lower Extremities. Radiology 2014; 273:153-9. [DOI: 10.1148/radiol.14132903] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Successful lower extremity salvage with free flap after endovascular angioplasty in peripheral arterial occlusive disease. J Plast Reconstr Aesthet Surg 2014; 67:1136-43. [DOI: 10.1016/j.bjps.2014.04.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 03/26/2014] [Accepted: 04/29/2014] [Indexed: 11/19/2022]
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Effect of iterative reconstruction algorithms on peripheral MDCT angiography virtual histology plaque volumes: have we been overestimating disease burden? Clin Imaging 2014; 38:821-5. [PMID: 25069752 DOI: 10.1016/j.clinimag.2014.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/07/2014] [Accepted: 06/19/2014] [Indexed: 11/22/2022]
Abstract
Our objective was to compare plaque volumes of multidetector computed tomographic images reconstructed using adaptive statistical iterative reconstruction (ASIR), model-based iterative reconstruction (MBIR), and filtered back projection (FBP). We reviewed 25 patients for a total of 50 extremities imaged on the same scanner. Calcified plaque FBP volume (3468.2 ± 2634.8 mm(3)) was higher than ASIR (2548.1 ± 2166.5 mm(3)). Calcified plaque FBP volume was higher than MBIR (mean=2345.7 ± 1935.4 mm(3)). Our findings suggest that traditional FBP methods overestimate disease compared to newer reconstruction methods.
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Gupta P, Sinha A, Khandelwal N. Automatic scan triggering software "confused": Computed tomography angiography in foot arteriovenous malformation! Indian J Radiol Imaging 2014; 24:125-8. [PMID: 25024519 PMCID: PMC4094961 DOI: 10.4103/0971-3026.134387] [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] [Indexed: 11/04/2022] Open
Abstract
Multidetector computed tomography angiography (MDCTA) has become a well-established modality for limb angiography for a variety of indications. The technique of MDCTA depends on the scanner features including the number of detector rows, rotation speeds and single or dual source energy. Integral to a diagnostic quality CTA is the acquisition timing. Various techniques are available for determining the appropriate timing of scan acquisition which includes fixed delay, test bolus and the bolus tracking technique. The transit times of contrast from the aorta to the peripheral arteries shows a wide variability and is dependent upon the inter individual hemodynamic states. The bolus tracking technique is the most preferred one which allows reliable scan timing with acceptable contrast volume and radiation dose. Pitfalls with all these techniques are well described and we report one such technical pitfall in a case of left foot arteriovenous malformation (AVM) where the bolus tracking technique employed for scan triggering failed to initiate acquisition.
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Affiliation(s)
- Pankaj Gupta
- Department of Radio-diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anindita Sinha
- Department of Radio-diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio-diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Diagnostic efficiency of low-dose CT angiography compared with conventional angiography in peripheral arterial occlusions. AJR Am J Roentgenol 2014; 201:W906-14. [PMID: 24261398 DOI: 10.2214/ajr.12.10209] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the diagnostic efficiency and radiation dose of peripheral arterial CT angiography (CTA) performed at a low tube voltage of 70 kV in comparison with conventional angiography. SUBJECTS AND METHODS Thirty consecutive patients (body mass index ≤ 25 kg/m(2)) with known or suspected peripheral arterial occlusion diseases underwent both CTA at a low tube voltage of 70 kV and conventional angiography. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of peripheral arterial CTA were evaluated. The radiation dose was recorded. RESULTS Diagnostic CTA images were obtained in all patients. CTA allowed accurate identification, characterization, and measurement of all peripheral arterial occlusive diseases. In conventional angiography, 360 diseased segments were found among the 810 segments evaluated. The sensitivity, specificity, PPV, NPV, and accuracy of CTA were 100% (95% CI, 98.81-100%), 93.5% (90.96-95.36%), 90.86% (87.38-93.45%), 100% (99.17-100%), and 96.05% (94.48-97.19%), respectively, with a kappa value of 0.92 (excellent agreement). The mean CT dose index was 3.71 ± 0.8 mGy, and the dose-length product was 446.6 ± 35.7 mGy × cm. The effective dose was 1.94 ± 0.21 mSv for CTA and 4.41 ± 0.64 mSv for conventional angiography. CONCLUSION CTA of peripheral arteries with a low tube voltage of 70 kV provides reliable information and serves as a rapidly performed and easily available "one-stop-shop" imaging modality in the diagnosis of peripheral arterial occlusion diseases.
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Garcia MJ. Computed Tomography Angiography: Peripheral and Visceral Vascular System. PANVASCULAR MEDICINE 2014:1-28. [DOI: 10.1007/978-3-642-37393-0_36-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 09/02/2023]
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Baxa J, Vendiš T, Moláček J, Stěpánková L, Flohr T, Schmidt B, Korporaal JG, Ferda J. Low contrast volume run-off CT angiography with optimized scan time based on double-level test bolus technique--feasibility study. Eur J Radiol 2013; 83:e147-55. [PMID: 24380637 DOI: 10.1016/j.ejrad.2013.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 12/03/2013] [Accepted: 12/05/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE To verify the technical feasibility of low contrast volume (40 mL) run-off CT angiography (run-off CTA) with the individual scan time optimization based on double-level test bolus technique. MATERIALS AND METHODS A prospective study of 92 consecutive patients who underwent run-off CTA performed with 40 mL of contrast medium (injection rate of 6 mL/s) and optimized scan times on a second generation of dual-source CT. Individual optimized scan times were calculated from aortopopliteal transit times obtained on the basis of double-level test bolus technique--the single injection of 10 mL test bolus and dynamic acquisitions in two levels (abdominal aorta and popliteal arteries). Intraluminal attenuation (HU) was measured in 6 levels (aorta, iliac, femoral and popliteal arteries, middle and distal lower-legs) and subjective quality (3-point score) was assessed. Relations of image quality, test bolus parameters and arterial circulation involvement were analyzed. RESULTS High mean attenuation (HU) values (468; 437; 442; 440; 342; 274) and quality score in all monitored levels was achieved. In 91 patients (0.99) the sufficient diagnostic quality (score 1-2) in aorta, iliac and femoral arteries was determined. A total of 6 patients (0.07) were not evaluable in distal lower-legs. Only the weak indirect correlation of image quality and test-bolus parameters was proved in iliac, femoral and popliteal levels (r values: -0.263, -0.298 and -0.254). The statistically significant difference of the test-bolus parameters and image quality was proved in patients with occlusive and aneurysmal disease. CONCLUSION We proved the technical feasibility and sufficient quality of run-off CTA with low volume of contrast medium and optimized scan time according to aortopopliteal transit time calculated from double-level test bolus.
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Affiliation(s)
- Jan Baxa
- Department of Imaging Methods, University Hospital and Charles University Medical School in Pilsen, Czech Republic.
| | - Tomáš Vendiš
- Department of Imaging Methods, University Hospital and Charles University Medical School in Pilsen, Czech Republic
| | - Jiří Moláček
- Department of Surgery, University Hospital and Charles University Medical School in Pilsen, Czech Republic
| | - Lucie Stěpánková
- Department of Internal Medicine, University Hospital and Charles University Medical School in Pilsen, Czech Republic
| | - Thomas Flohr
- Siemens Healthcare, Computed Tomography Division, Forchheim, Germany
| | - Bernhard Schmidt
- Siemens Healthcare, Computed Tomography Division, Forchheim, Germany
| | | | - Jiří Ferda
- Department of Imaging Methods, University Hospital and Charles University Medical School in Pilsen, Czech Republic
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Traupe T, Ortmann J, Stoller M, Baumgartner I, de Marchi SF, Seiler C. Direct quantitative assessment of the peripheral artery collateral circulation in patients undergoing angiography. Circulation 2013; 128:737-44. [PMID: 23817577 DOI: 10.1161/circulationaha.112.000516] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the fact that numerous studies have pursued the strategy of improving collateral function in patients with peripheral artery disease, there is currently no method available to quantify collateral arterial function of the lower limb. METHODS AND RESULTS Pressure-derived collateral flow index (CFIp, calculated as (occlusive pressure-central venous pressure)/(aortic pressure-central venous pressure); pressure values in mm Hg) of the left superficial femoral artery was obtained in patients undergoing elective coronary angiography using a combined pressure/Doppler wire (n=30). Distal occlusive pressure and toe oxygen saturation (Sao2) were measured for 5 minutes under resting conditions, followed by an exercise protocol (repetitive plantar-flexion movements in supine position; n=28). In all patients, balloon occlusion of the superficial femoral artery over 5 minutes was painless under resting conditions. CFIp increased during the first 3 minutes from 0.451±0.168 to 0.551±0.172 (P=0.0003), whereas Sao2 decreased from 98±2% to 93±7% (P=0.004). Maximal changes of Sao2 were inversely related to maximal CFIp (r(2)=0.33, P=0.003). During exercise, CFIp declined within 1 minute from 0.560±0.178 to 0.393±0.168 (P<0.0001) and reached its minimum after 2 minutes of exercise (0.347±0.176), whereas Sao2 declined to a minimum of 86±6% (P=0.002). Twenty-five patients (89%) experienced pain or cramps/tired muscles, whereas 3 (11%) remained symptom-free for an occlusion time of 10 minutes. CFIp values were positively related to the pain-free time span (r(2)=0.50, P=0.002). CONCLUSIONS Quantitatively assessed collateral arterial function at rest determined in the nonstenotic superficial femoral artery is sufficient to prevent ischemic symptoms during a total occlusion of 5 minutes. During exercise, there is a decline in CFIp that indicates a supply-demand mismatch via collaterals or, alternatively, a steal phenomenon. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT01742455.
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Affiliation(s)
- Tobias Traupe
- Department of Cardiology, University Hospital, CH-3010 Bern, Switzerland
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Yang RY, Jaskolka JD, Tan KT, Roche-Nagle G. Prevalence and significance of extravascular incidental findings on computed tomographic angiography and magnetic resonance angiography. Vascular 2013; 21:355–62. [DOI: 10.1177/1708538112473973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) are routinely used to evaluate patients with vascular disease. They have the ability to detect unexpected non-vascular pathology. The purpose of this study was to determine the prevalence and significance of extravascular incidental findings in patients undergoing CTA or MRA. A retrospective review of 737 patients who underwent CTA and 184 patients who underwent MRA during a five-year period was performed. Incidental findings were classified as low, moderate or high significance findings. For patients with high significance extravascular findings, assessment of the rates of appropriate follow-up was conducted. Among the CTA patients, 539 (73.1%) had incidental findings. Low, moderate and high significance findings were discovered in 514 (69.7%), 95 (12.9%) and 41 (5.6%) patients, respectively. Twenty (48.8%) patients with high significance findings received appropriate follow-up investigations. Among the MRA patients, 95 (51.6%) had extravascular findings. Low, moderate and high significance findings were present in 80 (43.5%), 27 (14.7%), and 3 (1.6%) patients, respectively. Two (66.7%) patients with high significance findings were properly followed up. In conclusion, incidental findings on CTA and MRA are very common. A small percentage of these findings could be serious and were not all adequately followed-up in our study population. Referring physicians should be aware of the potential for serious incidental findings and manage them appropriately.
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Affiliation(s)
- Roy Y Yang
- Division of Vascular Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jeffrey D Jaskolka
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Kong T Tan
- Division of Vascular & Interventional Radiology, Joint Department of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
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Morris MF, Suri RM, Akhtar NJ, Young PM, Gruden JF, Burkhart HM, Williamson EE. Computed Tomography as an Alternative to Catheter Angiography Prior to Robotic Mitral Valve Repair. Ann Thorac Surg 2013; 95:1354-9. [DOI: 10.1016/j.athoracsur.2012.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 12/04/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
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Can previous diagnostic examinations prevent preoperative angiographic assessment of the internal mammary perforators for (micro)surgical use? Ann Plast Surg 2013; 72:560-5. [PMID: 23486113 DOI: 10.1097/sap.0b013e318268a896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIM Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. METHODS A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. RESULTS All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. CONCLUSIONS Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.
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Ibrahim NMA, Elsaeed HH. Popliteal artery entrapment syndrome evaluation with multislice CT angiography. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2012.10.005] [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] Open
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Diagnostic Accuracy of CT Angiography in the Evaluation of Stenosis in Lower Limbs. J Comput Assist Tomogr 2013; 37:419-25. [DOI: 10.1097/rct.0b013e31828730ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Oca Pernas R, Delgado Sánchez-Gracián C, Tardáguila de la Fuente G, Fernández Del Valle A, Silva Priegue N, González Vázquez M, Trinidad López C. Comparison of image quality and radiation dose in computed tomography angiography of the peripheral arteries using tube voltage of 80 kV versus 100 kV. RADIOLOGIA 2012; 56:541-7. [PMID: 23276715 DOI: 10.1016/j.rx.2012.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 06/18/2012] [Accepted: 06/28/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the image quality and dose of radiation in two groups of patients undergoing CT angiography of the lower limbs, one with tube voltage of 80 kV and the other with tube voltage of 100 kV. MATERIAL AND METHODS We performed CT angiography of the lower limbs in 60 patients with suspected peripheral arterial disease. Patients were randomly assigned to one of two groups; in one group, CT angiography was performed using a tube voltage of 80kV, whereas in the other it was performed using 100 kV. The remaining acquisition parameters were the same in both groups. The images were analyzed by quantifying vascular density (VD) and noise (N) and by calculating the quotients density/noise (QVDN) and contrast/noise (QCN). Two radiologists working independently evaluated the subjective quality of the images. We calculated the estimated effective dose (EED) based on the dose-length product (DLP). RESULTS In the group studied at 80 kV, VD was significantly higher (462.5 UH ± 95.6 vs. 372 UH ± 100.9; P<.001), QVDN was significantly higher (241.9 ± 48.1 vs. 194.3 ± 49.6; P<.001), and there were trends toward higher N (21.3 UH ± 13 vs. 16.3 UH ± 3.5; P=.098) and toward higher QCN (21.4 ± 12.1 vs. 22.9 ± 9.1; P=.15). No significant differences were found in the subjective quality of the images. The EED was significantly lower in the group studied at 80 kV (4.73 mSv ± 1.1 vs. 9.6 mSv ± 2.2; P<.001). CONCLUSION Using 80 kV instead of 100 kV for CT angiography of the lower limbs reduces the dose of radiation without affecting the diagnostic efficacy of the study.
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Affiliation(s)
- R Oca Pernas
- Servicio de Radiodiagnóstico, Hospital POVISA, Vigo, Pontevedra, España.
| | | | | | | | - N Silva Priegue
- Servicio de Radiodiagnóstico, Hospital POVISA, Vigo, Pontevedra, España
| | | | - C Trinidad López
- Servicio de Radiodiagnóstico, Hospital POVISA, Vigo, Pontevedra, España
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Role of multi-slice CT angiography versus Doppler ultrasonography and conventional angiography in assessment of aorto-iliac arterial disease. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2012. [DOI: 10.1016/j.ejrnm.2012.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Assessment of vascular contrast and depiction of stenoses in abdominopelvic and lower extremity vasculature: comparison of dual-energy MDCT with digital subtraction angiography. Acad Radiol 2012; 19:1149-57. [PMID: 22743115 DOI: 10.1016/j.acra.2012.04.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/12/2012] [Accepted: 04/13/2012] [Indexed: 12/22/2022]
Abstract
RATIONALE AND OBJECTIVES To assess whether dual-energy computed tomography (DECT) multidetector computed tomography (MDCT) angiography improves vascular contrast beyond MDCT angiography and digital subtraction angiography (DSA) while preserving the ability to precisely characterize stenoses, using DSA as reference standard. MATERIALS AND METHODS This prospective, Health Insurance Portability and Accountability Act-compliant, institutional review board-approved study was performed on 25 patients referred for lower extremity DECT angiography and subsequent DSA. Spectral data were postprocessed to create single-energy 120 kVp (MDCT series) and iodine-only (DECT series) datasets. The arterial tree was subdivided into 11 anatomical levels. Contrast-to-noise ratios (CNR) and corresponding coefficient -of variation (CV) of patent vessel segments were evaluated for DECT, MDCT, and DSA using analysis of variance comparisons. Degree of stenoses was determined for DECT, MDCT, and DSA and correlated with t-test, bivariate Pearson comparisons, and Bland-Altman plots. RESULTS Patent vasculature comprised 230 vessel segments. From infrarenal aorta to distal femoral arteries, DECT showed higher CNR compared to DSA and MDCT (P < .05); distal to the popliteal arteries, DSA achieved higher CNR (P < .05). Analyses of contrast homogeneity showed minimal CV above the knee for MDCT (≤9%) and for DSA below the knee (≤7%). Stenotic vasculature comprised 33 segments. Significant correlations of stenosis severity were found comparing DECT and MDCT with DSA as reference standard showing a 0.04-fold mean underestimation of stenoses on MDCT and no detectable mean variation on DECT compared with DSA. CONCLUSION DECT angiography improved contrast in vascular abdominopelvic and thigh distributions beyond MDCT angiography and DSA while preserving the ability to precisely assess severity of stenoses, using DSA as an accepted reference standard.
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Pinho DF, Kulkarni NM, Krishnaraj A, Kalva SP, Sahani DV. Initial experience with single-source dual-energy CT abdominal angiography and comparison with single-energy CT angiography: image quality, enhancement, diagnosis and radiation dose. Eur Radiol 2012; 23:351-9. [PMID: 22918562 DOI: 10.1007/s00330-012-2624-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 06/24/2012] [Accepted: 06/28/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Daniella F Pinho
- Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, 55 Fruit Street, White 270, Boston, MA 02114, USA.
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Bag S, Behera A, Khandelwal N, Bapuraj JR, Vasishta RK. Improvement in Blood Supply After "Heparin-Dextran" Therapy in Patients of Buerger's Disease with Critical Limb Ischemia. Indian J Surg 2012; 75:462-8. [PMID: 24465103 DOI: 10.1007/s12262-012-0537-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 05/31/2012] [Indexed: 11/28/2022] Open
Abstract
Alleviating the agonizing pain of critical limb ischemia (CLI) in patients of Buerger's disease (BD) has been challenging, due to lack of definitive treatment; "Heparin-Dextran" infusion has been tried in this study. Assessment of clinical improvement and vascular changes following therapy. Patients with CLI admitted to emergency surgical ward were studied prospectively. BD was diagnosed by Shionoya's criteria, and confirmed by digital subtraction angiography (DSA). Heparin and Dextran intravenous infusion was administered for 10 days. Severity of rest pain, ischemic changes in the feet, claudication distance and ankle brachial index (ABI) were estimated prior to therapy, at completion and 3 weeks after therapy. Vascular changes were assessed by CT angiography (CTA) performed prior to and 3 weeks after therapy. Twenty consecutive patients were studied. Successful hemodilution reflected by decreased hematocrit (37.4 % to 32.6 %, p < 0.05) and increased mean ABI (0.46 to 0.83, p < 0.01), improved rest pain in 75 % patients (p < 0.001), increased claudication distance in 94 % (p < 0.05) and ulcers healing in 70 % patients. CTA revealed recanalised vessels (decreased length of occluded segments) in 10 (50 %, p = 0.005), increased collaterals in 12 (60 %, p < 0.01) and improved distal run-off in 13 (65 %, p < 0.01) patients. "Heparin-Dextran" therapy in patients of CLI from BD improves tissue perfusion by increasing collaterals and recanalisation of vessels, resulting in significant relief from rest pain and clinical improvements. CTA is as efficacious as DSA for evaluation of BD.
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Affiliation(s)
- Sanand Bag
- Departments of General Surgery, Post Graduate Institute of Medical Education & Research, Chandigarh, 160 012 India
| | - Arunanshu Behera
- Departments of General Surgery, Post Graduate Institute of Medical Education & Research, Chandigarh, 160 012 India ; Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012 India
| | - Niranjan Khandelwal
- Departments of Radiology and Imaging Sciences, Post Graduate Institute of Medical Education & Research, Chandigarh, 160 012 India
| | - J R Bapuraj
- Departments of Radiology and Imaging Sciences, Post Graduate Institute of Medical Education & Research, Chandigarh, 160 012 India
| | - Rakesh Kumar Vasishta
- Departments of Histopathology, Post Graduate Institute of Medical Education & Research, Chandigarh, 160 012 India
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Iezzi R, Santoro M, Marano R, Di Stasi C, Dattesi R, Kirchin M, Tinelli G, Snider F, Bonomo L. Low-Dose Multidetector CT Angiography in the Evaluation of Infrarenal Aorta and Peripheral Arterial Occlusive Disease. Radiology 2012; 263:287-98. [PMID: 22332067 DOI: 10.1148/radiol.11110700] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Roberto Iezzi
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, A. Gemelli Hospital-Catholic University, L.go A Gemelli 8, 00168 Rome, Italy.
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Hsu YC, Shih YYI, Chang CF, Huang GS. A rare case of coiling of the brachial artery: a description of the sonographic features. J Med Ultrason (2001) 2012; 39:21-4. [PMID: 27278701 DOI: 10.1007/s10396-011-0330-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Accepted: 09/05/2011] [Indexed: 01/09/2023]
Abstract
We report the case of a patient with 360° coiling of the brachial artery that had been previously misdiagnosed as aneurysms of the right brachial artery on sonography performed at another institution. The previous misdiagnosis occurred due to sonographic pitfalls in gray-scale and color imaging, which led the operator to make a false interpretation. Knowledge of Doppler analysis and sonographic interpretation of arterial coiling may improve the diagnostic accuracy for this condition.
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Affiliation(s)
- Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu 114, Taipei, Taiwan, R.O.C
| | - Yen-Yu I Shih
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, 8403 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Ching-Feng Chang
- Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu 114, Taipei, Taiwan, R.O.C.
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49
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Hoshino T, Ichikawa K, Terakawa S, Katsuma Y, Fujimura I, Ueda Y, Miura Y, Nishimura K. [Impact of iterative reconstruction on shape reproducibility of three-dimensional computed tomography]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2012; 68:1624-1630. [PMID: 23257592 DOI: 10.6009/jjrt.2012_jsrt_68.12.1624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The purpose of this study was to evaluate the effect of an iterative reconstruction method (IR) on shape reproducibility in three-dimensional (3D) computed tomography images. We used an IR (sinogram-affirmed iterative reconstruction: SAFIRE) implemented in a 64-channel multi slice computed tomography system (Siemens, SOMATOM Definition AS). We scanned a simulated vessel phantom with 180-HU vessel contrast at various radiation doses and reconstructed axial images of filtered back projection (FBP) and SAFIRE. Then we reconstructed multi-planar reconstruction (MPR) and volume rendering (VR) images from the axial images. Roundness was evaluated from MPR images and vessel surface roughness was evaluated from pixel value profiles of a vessel in VR images and visual evaluation by radiological technologists. In comparison on equivalent dose, the roundness and roughness were improved with increase of SAFIRE strength level. However, in comparison on equivalent noise (standard deviation: SD) of axial images, SAFIRE strength levels of 2 to 5 were significantly inferior to FBP (p<0.05). SAFIRE strength of 1 with a dose reduction of 19% maintained the shape reproducibility in all evaluations. Therefore, it would be not appropriate to use the SD of axial image as index for the dose reduction rate determination of 3D-CT images.
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50
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Napoli A, Anzidei M, Zaccagna F, Cavallo Marincola B, Zini C, Brachetti G, Cartocci G, Fanelli F, Catalano C, Passariello R. Peripheral Arterial Occlusive Disease: Diagnostic Performance and Effect on Therapeutic Management of 64-Section CT Angiography. Radiology 2011; 261:976-86. [DOI: 10.1148/radiol.11103564] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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