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Peripheral Arterial Disease: Therapeutic Confidence of CT versus Digital Subtraction Angiography and Effects on Additional Imaging Recommendations¹

¹ From the Departments of Radiology (M.E.A.P.M.A., M.C.J.M.K., P.M.T.P., M.G.M.H.) and Epidemiology and Biostatistics (M.E.A.P.M.A., M.C.J.M.K., T.S., M.G.M.H.) and Division of Vascular Surgery (M.R.H.M.v.S., H.v.U.), Erasmus MC, Rm EE21–40a, Dr Molewaterplein 50, 3015 GE Rotterdam, the Netherlands; and Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass (M.G.M.H.). From the 2002 RSNA scientific assembly. Received October 1, 2003; revision requested December 18; revision received January 19, 2004; accepted February 17. Supported by a Health Care Efficiency Grant from the Health Care Insurance Board (00112) and a Program Grant from the Netherlands Organization for Scientific Research (904–66-091). Address correspondence to M.G.M.H. (e-mail: m.hunink@erasmusmc.nl).

PURPOSE: To compare multi–detector row computed tomographic (CT) angiography and digital subtraction angiography (DSA) prior to revascularization in patients with symptomatic peripheral arterial disease for the purpose of assessing recommendations for additional imaging and physician confidence ratings for chosen therapy.

MATERIALS AND METHODS: In a randomized controlled trial, 73 patients were assigned to CT angiography, and 72 were assigned to DSA. Physician confidence in the treatment decision was measured as a continuous outcome on a scale of 0–10 (uncertain to certain) and as a dichotomous outcome (further imaging recommended, yes or no). Mean confidence scores and additional imaging recommendations were compared between CT and DSA groups in an intention-to-diagnose-and-treat analysis. To detect trends in confidence, confidence scores were plotted over time, and multiple linear regression analysis was performed. To detect trends in additional imaging recommendations, logistic regression analysis was used. Data from eligible nonrandomized patients were analyzed separately.

RESULTS: No statistically significant difference in baseline characteristics between randomized groups was found. CT had a lower confidence score than did DSA (7.2 vs 8.2, P < .001). Further imaging was recommended more often after CT (25 of 71 patients, 35%) than after DSA (nine of 66 patients, 14%; P = .003). Analysis of trends demonstrated increasing (but not statistically significant) confidence in CT and stable confidence in DSA. No significant difference was found in baseline characteristics between randomized and nonrandomized patients. Among nonrandomized patients, no significant difference in mean confidence score (8.2 vs 8.3, P = .26) was found between CT (n = 24) and DSA (n = 26).

CONCLUSION: With CT angiography, physician confidence decreases with an associated increase in additional imaging prior to revascularization in patients with symptomatic peripheral arterial disease. Given that CT is less invasive than DSA, results suggest that CT may replace DSA in selected cases.

© RSNA, 2004

Index terms: Arteries, peripheral • Computed tomography (CT), angiography • Digital subtraction angiography, comparative studies

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