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Vascular and Interventional Radiology |
1 From the Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305-5105. Received June 15, 1999; revision requested August 3; revision received August 17; accepted September 14. Supported by National Institutes of Health grant R01HL58915. Address correspondence to G.D.R. (e-mail: grubin @stanford.edu).
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Abstract |
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MATERIALS AND METHODS: Forty-eight patients with aortic aneurysm or dissection underwent four- and one-channel CT angiography. Scan pairs covered the thoracic inlet to the diaphragm (n = 10) and supraceliac abdominal aorta (n = 19) or thoracic inlet (n = 19) to the femoral arterial bifurcations. For four-channel CT, nominal section thickness and pitch were 2.5 mm and 6.0, respectively, and for one-channel CT, 3.0 mm and 2.0 to the infrarenal aorta and 5.0 mm and 2.0 to the femoral arteries. Effective section thickness, scanning duration, scanning coverage, dose of iodinated contrast material, and mean aortoiliac attenuation were compared. Data were summarized as speed (coverage/duration), scanning efficiency (speed/section thickness), and contrast efficiency (mean aortic attenuation/dose of contrast material).
RESULTS: At four- versus one-channel CT, CT angiography was 2.6 times faster, scanning efficiency was 4.1 times greater, contrast efficiency was 2.5 times greater, dose of contrast material was reduced (mean, 57%; 97 vs 232 mL) without a significant change in aortic enhancement, and sections were thinner (mean, 40%; 3.2 vs 5.3 mm) despite a 59% shorter scanning duration (22 vs 56 seconds).
CONCLUSION: Substantially reduced doses of contrast medium, shorter scanning durations, and narrower effective sections result with four- versus one-channel CT aortography. No advantages of one-channel CT aortography were demonstrated.
Index terms: Aneurysm, aorta, 94.73, 98.73, • Aorta, CT, 94.12912, 94.12914, 94.12915, 94.12916, 98.12912, 98.12914, 98.12915, 98.12916 • Aorta, dissection, 94.74, 98.74 • Computed tomography (CT), angiography, 94.12916, 98.12916 • Computed tomography (CT), comparative studies • Computed tomography (CT), helical, 94.12915, 98.12915 • Computed tomography (CT), technology
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Introduction |
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With the recent introduction of multiple detector-row CT scanners, CT angiography can be performed more efficiently (more quickly and with higher longitudinal spatial resolution) than was possible with single detector-row CT scanners (8). Currently, multiple detector-row four-channel CT scanners acquire up to four channels of data simultaneously from interweaving helices. A single x-ray fan beam is used, and the length of the individual detector elements determines the section thickness (9). Table speeds of up to six times the nominal section thickness per gantry rotation (pitch, 6.0) are substantially faster than those of single-channel CT with a pitch of 2.0.
The purpose of this study was to test the hypothesis that the increased scanning efficiency of four-channel CT compared with one-channel CT would improve CT angiography by allowing for better longitudinal resolution, greater anatomic coverage during a single breath hold, and reduced doses of contrast medium.
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MATERIALS AND METHODS |
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Indications for study of the thoracic aorta were pre- or postoperative assessment of thoracic aortic aneurysm (n = 9) or aortic dissection (n = 1). Indications for study of the abdominal aorta and iliac arteries were pre- or postoperative assessment of abdominal aortoiliac aneurysm (n = 18) or isolated iliac arterial aneurysm (n = 1). Indications for study of the entire thoracoabdominal aortoiliac system were pre- or postoperative assessment of aortic dissection (n = 11) or thoracoabdominal aortic aneurysm (n = 8). One-channel CT angiographic examination preceded four-channel CT angiographic examination in all patients, and the time between examinations ranged from 4 to 1,551 days (mean, 299 days).
Acquisition Protocols
One-channel CT angiograms were acquired by using either a CTi scanner (GE Medical Systems, Milwaukee, Wis) with a 1-second gantry rotation period or a Somatom Plus 4 CT scanner (Siemens Medical Systems, Erlangen, Germany) with a 0.75-second gantry rotation period. Forty-one scans were acquired with the CTi, and seven scans were acquired with the Somatom Plus 4. Triage to the scanners was based on the availability of two imaging facilities equipped with either the CTi or Somatom Plus 4 scanner.
CT acquisition parameters are summarized in Table 1. With the Somatom Plus 4 scanner, 3-mm collimation with a pitch of 2.0 was used for all acquisitions. With the CTi, 3-mm collimation with a pitch of 2.0 was used for the thoracic aorta to the distal infrarenal aorta, and 5-mm collimation was used from the distal infrarenal abdominal aorta to the femoral arterial bifurcations. The specific implementation and rationale for the latter approach has been previously published (10). X-ray tube voltage was 120 kV, and the current varied between 200 and 280 mA, depending on the heat limitations of the tube.
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Transverse sections were reconstructed at intervals equal to half of the collimation by using 180° linear interpolation. The effective section thicknesses, defined as the full width at half maximum of the section sensitivity profile, were 4.3 and 7.1 mm for 3- and 5-mm collimated scans, respectively. These values were directly measured by using a 15-µm-thick aluminum disk that was perpendicularly oriented at the center of the scanning gantry. The disk was advanced through the gantry during scanning by using the imaging collimation and pitch combinations previously described. Sections were reconstructed at increments equal to one-tenth of the nominal collimator width. Section sensitivity profiles were derived from the mean attenuation in the circular regions of interest that encompassed the central 600 pixels on each reconstructed section (12).
All four-channel angiograms were acquired on a Lightspeed QXi CT scanner with a 0.8-second gantry rotation period by using 2.5-mm nominal section thickness, a pitch of 6.0, and a table speed of 15 mm per rotation (18.75 mm/sec). Data were always acquired during a single–breath-hold acquisition in a superior-to-inferior direction. The x-ray tube voltage was 120 KV, and the current was 300 mA. The protocol for the injection of contrast material at one-channel CT was used at four-channel CT. Transverse sections were reconstructed at intervals equal to half of the collimation by using a modified 180° linear interpolation process that incorporates views on the basis of a balance between section profile broadening, helical artifact, and image noise (9). The effective section thickness, defined as the full width at half maximum of the section sensitivity profile, was 3.2 mm and was measured by using the same method as that used at one-channel CT.
All one- and four-channel CT angiographic data were reformatted in our 3D imaging laboratory into volume renderings, shaded-surface displays, maximum intensity projections, and curved planar reformations by one of two 3D imaging technologists (L.J.L., M. C. Sofilos). Two curved planar reformations were created through the longitudinal axis of the aorta and the following arteries when they were present on the scan: both common and external iliac, brachiocephalic, left common carotid, left subclavian, celiac, superior mesenteric, renal, and inferior mesenteric. The two curves were created at 90° intervals about the longitudinal axis of the artery.
Data from the bones were removed by using a combination of region-growing Boolean operations and region-of-interest drawings. The opacity-transfer function for volume rendering and the thresholds for shaded-surface displays were determined to maximize vascular visualization while minimizing nonvascular visualization. Twelve volume renderings and shaded-surface displays were created every 30° about the craniocaudal axis, and six maximum intensity projections were created every 30° about the craniocaudal axis at the frontal aspect between the right and left lateral views. The technologists who created the reformatted images photographed the images with customized window width and level settings to allow clear delineation of the enhanced lumen, mural calcium, mural atheroma and/or plaque, and extravascular tissues.
Data Collection and Analysis
A radiologist (M. C. Shiau) retrospectively recorded the scanning duration (in seconds), scanning coverage (in millimeters), and nominal section thickness (in millimeters) from annotations that were automatically attached to the CT images by the scanner at the time of acquisition. The dose of iodinated contrast material (in milliliters of a solution containing 300 mg of iodine per milliliter) was recorded at the time of image acquisition by the nurse or technologist who performed the injection and was collated with the other scanning data (by M. C. Shiau). The mean aortoiliac attenuation of each scan was calculated as the mean of the mean of the attenuation measurements within elliptical regions-of-interest placed (by M. C. Shiau) within the aorta or iliac arteries every 20-mm along the z axis. When the ascending and descending thoracic aortas or when the two common and external iliac arteries were present on the same transverse reconstruction, the mean of the attenuation measurements within the two structures was calculated.
Three variables were defined to summarize the data. Scanning speed was defined as the scanning coverage divided by the scanning duration. Scanning efficiency was defined as the scanning speed divided by the mean effective section thickness of the scan. Contrast efficiency was defined as the mean aortoiliac attenuation divided by the dose of contrast material.
The mean, SD, and 95% CIs of the measurements were calculated for each of the three anatomic regions studied. Statistically significant differences were assessed for a P value of less than .05 and were identified for comparisons in which the 95% CIs of the measurements did not overlap.
All CT images, including the transverse reconstructions, volume renderings, shaded-surface displays, maximum intensity projections, and curved planar reformations, were reviewed by two of four radiologists (G.D.R., M. C. Shiau, A.N.L., S.T.K.). The overall quality of vascular visualization, distinction of mural thrombus and plaque, and degree of motion-related artifacts were subjectively assessed.
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RESULTS |
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Image quality subjectively improved with four-channel CT angiography compared with one-channel CT angiography (Figs 1–4). Transversely and obliquely oriented arteries were visualized with fewer tendencies for attenuation dropout. Mural calcium was more discrete, smaller distal branches were visualized, and stenotic regions had less degradation due to volume averaging. Finally, motion effects throughout the chest (especially in the heart) were substantially reduced due to the spread of the cardiac cycle across a greater longitudinal distance.
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DISCUSSION |
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Scanning duration has two critical influences—duration of the breath hold and dose of the contrast medium. Most patients who undergo CT angiography have little difficulty with a 30–35-second breath hold when it is preceded by hyperventilation (1,3,17,18). Although the 1-second one-channel CT scanner required up to 52 seconds (which included 5 seconds for the collimation to change from 3 to 5 mm) to acquire the abdominal aortoiliac scan, a 30-second breath hold followed by quiet breathing was sufficient, because respiratory misregistration was insubstantial in the pelvis.
Conversely, the entire thoracoabdominal aortoiliac system cannot be imaged during a single breath hold, as substantial respiratory misregistration will occur from the thoracic inlet to the pelvic brim. As a result, with one-channel CT, we acquired these images in two steps: The abdominal aortoiliac system was imaged first, and then the thoracic aorta was imaged. The total scanning duration for this protocol was 54–87 seconds, not including the 5 seconds required for the collimation to change from 3 to 5 mm in the distal abdominal aorta. This delay resulted in misregistration at the interface of the thoracic and abdominal scans. More important, the dose of the contrast material was uncomfortably high for the patient.
Because we believe that the optimal CT angiogram is acquired with the administration of an intravenous bolus of contrast medium with a duration equivalent to the scanning duration, longer scanning durations require the use of more contrast medium. To image the entire thoracoabdominal aortoiliac system with one-channel CT angiography, doses of contrast medium ranged from 234 to 368 mL (70–110 g of iodine). These doses are substantially higher than those routinely used for CT scanning, resulting in concern for renal toxicity. With the improved scanning speed of four-channel CT, the dose of contrast medium for thoracoabdominal aortoiliac imaging decreased by an mean of 201 mL to 94–140 mL (28–42 g of iodine). This decrease has potentially reduced the morbidity associated with thoracoabdominal aortoiliac CT angiography.
In fact, the number of thoracoabdominal aortoiliac CT angiographic studies increased by 83%, whereas all other CT aortographic examinations increased by only 14% when we compared study volumes at our institution from January through May 1998 (one-channel CT) to January through May 1999 (four-channel CT). The increased number of thoracoabdominal aortoiliac CT angiographic examinations is both a reflection of the improved safety of scanning with lower doses of contrast medium and of an increasing need to image the abdominal aortoiliac system concurrently with the thoracic aorta in the planning of endovascular interventions in the treatment of aneurysms and dissections.
Similar reductions in the dose of contrast medium were observed in the other anatomic territories studied. In fact, thoracic CT aortography was performed with a mean of 69 mL of contrast medium (range, 57–80 mL). This dose (17–24 g of iodine) is lower than the dose previously reported for CT aortography. Although the difference was not significant, it is interesting to note that the mean thoracic aortic attenuation with four-channel CT angiography was 9% (30 HU) less than that of one-channel CT angiography, with the same concentration of contrast medium and injection rate.
Although the dose of contrast material was calculated to provide a constant flow of iodine for the entire duration of scanning, we observed a weak correlation between the dose of contrast material and aortic enhancement with thoracic four-channel CT aortography (R2 = 0.52, n = 10). Further, the two patients with a mean aortic attenuation values of less than 200 HU received the smallest doses of contrast medium (57 and 61 mL). While aortic enhancement is multifactorial and heavily dependent on patient weight, it is important to recognize that a portion of the injectant will pool within the venous system between the injection site and the heart. As injection volumes decrease to 60 mL or less, a substantial proportion of the bolus may not reach the heart during the scanning window due to venous pooling. The use of bolus of saline as a chaser has been demonstrated to improve vascular enhancement because the venous system is cleared of pooled contrast medium (19). In addition, higher volumes of dilute contrast medium have been shown to improve vascular enhancement in part because a smaller proportion of the dose of iodine is left to pool in the venous system (20). We have temporarily set our minimum contrast volume to 65 mL while we evaluate other strategies for the delivery of contrast medium.
Another important advantage of four-channel CT angiography is the improvement in image quality. Faster acquisition allows for improved consistency in the phase of enhancement throughout the imaging volume. We chose to use some of the efficiency advantages of four-channel CT angiography to improve our longitudinal spatial resolution, as well as to shorten our scanning duration. The effective section thickness was narrowed by a factor of 0.55–0.74. This improvement is readily demonstrable in improved image quality (Figs 2–4).
The speed of multiple detector-row CT systems is dependent on two primary specifications—the number of channels simultaneously acquired and the gantry rotation period. The scanner that we investigated simultaneously collects four channels of data and has an 800-msec gantry rotation period. Multiple detector-row four-channel CT scanners with a 500-msec gantry rotation period have been developed and, at the time this article was written, are being introduced into clinical practice. The advantage of a 500-msec gantry rotation compared with an 800-msec gantry rotation is a 62.5% increase in speed, provided that image quality can be maintained with improved detector efficiency or with the use of x-ray tubes with 62.5% greater output to maintain photon flux per rotation.
In the future, eight- or 16-channel systems might be developed, further increasing the scanning speed without requiring additional output from the x-ray tube. An eight-channel 500-msec scanner could be used to image the entire aortoiliac system with a 1.0- or 2.5-mm nominal section thickness in 23 or 9 seconds, respectively. The abdominal aorta and lower extremity run-off to the ankles could be imaged with a 2.5-mm nominal section thickness in 22 seconds. With a 16-channel system, the abdominal aorta and lower extremity run-off could be imaged in 11 seconds. The entire vascular system, from head to toe, of a 170-cm-tall person could be imaged in 14 seconds with 2.5-mm nominal section thickness and a table feed rate of 120 mm/sec.
The use of multiple detector-row CT, compared with single detector-row CT, offers substantial improvements in the performance of CT angiography. Four-channel CT angiography of the aorta results in the use of substantially less contrast medium, shorter scanning durations, and narrower effective sections, compared with one-channel CT angiography of the aorta. We found no demonstrable advantages of using one-channel CT for CT aortography.
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Footnotes |
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A. Mallouhi, M. Rieger, B. Czermak, M. C. Freund, P. Waldenberger, and W. R. Jaschke Volume-Rendered Multidetector CT Angiography: Noninvasive Follow-Up of Patients Treated with Renal Artery Stents Am. J. Roentgenol., January 1, 2003; 180(1): 233 - 239. [Abstract] [Full Text] [PDF]
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D. Maintz, B. Tombach, K.-U. Juergens, S. Weigel, W. Heindel, and R. Fischbach Revealing In-Stent Stenoses of the Iliac Arteries: Comparison of Multidetector CT with MR Angiography and Digital Radiographic Angiography in a Phantom Model Am. J. Roentgenol., November 1, 2002; 179(5): 1319 - 1322. [Abstract] [Full Text] [PDF]
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J. K. Willmann, J. E. Roos, A. Platz, T. Pfammatter, P. R. Hilfiker, B. Marincek, and D. Weishaupt Multidetector CT: Detection of Active Hemorrhage in Patients with Blunt Abdominal Trauma Am. J. Roentgenol., August 1, 2002; 179(2): 437 - 444. [Abstract] [Full Text] [PDF]
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 U J Schoepf, C R Becker, R D Bruening, B M Ohnesorge, A Huber, L-G Haw, H Hildebrandt, and M F Reiser Multislice CT angiography Imaging, December 15, 2001; 13(5): 357 - 365. [Abstract] [Full Text] [PDF]
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D. S. Katz and M. Hon CT Angiography of the Lower Extremities and Aortoiliac System with a Multi-Detector Row Helical CT Scanner: Promise of New Opportunities Fulfilled Radiology, October 1, 2001; 221(1): 7 - 10. [Full Text] [PDF]
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G. D. Rubin, A. J. Schmidt, L. J. Logan, and M. C. Sofilos Multi-Detector Row CT Angiography of Lower Extremity Arterial Inflow and Runoff: Initial Experience Radiology, October 1, 2001; 221(1): 146 - 158. [Abstract] [Full Text] [PDF]
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 L. P. Lawler and E. K. Fishman Multi-Detector Row CT of Thoracic Disease with Emphasis on 3D Volume Rendering and CT Angiography RadioGraphics, September 1, 2001; 21(5): 1257 - 1273. [Abstract] [Full Text] [PDF]
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S. C. Rankin, W. Jan, and C. G. Koffman Noninvasive Imaging of Living Related Kidney Donors: Evaluation with CT Angiography and Gadolinium-Enhanced MR Angiography Am. J. Roentgenol., August 1, 2001; 177(2): 349 - 355. [Abstract] [Full Text] [PDF]
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M. Macari, G. M. Israel, P. Berman, M. Lisi, A. J. Tolia, M. Adelman, and A. J. Megibow Infrarenal Abdominal Aortic Aneurysms at Multi-Detector Row CT Angiography: Intravascular Enhancement without a Timing Acquisition Radiology, August 1, 2001; 220(2): 519 - 523. [Abstract] [Full Text] [PDF]
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M. Simon, P. M. Boiselle, J. R. Choi, M. P. Rosen, K. Reynolds, and V. Raptopoulos Paddle-Wheel CT Display of Pulmonary Arteries and Other Lung Structures: A New Imaging Approach Am. J. Roentgenol., July 1, 2001; 177(1): 195 - 198. [Full Text] [PDF]
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T. R. Jones, R. T. Kaplan, B. Lane, S. W. Atlas, and G. D. Rubin Single- versus Multi-Detector Row CT of the Brain: Quality Assessment Radiology, June 1, 2001; 219(3): 750 - 755. [Abstract] [Full Text] [PDF]
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A. K. Hara, C. D. Johnson, R. L. MacCarty, T. J. Welch, C. H. McCollough, and W. S. Harmsen CT Colonography: Single- versus Multi-Detector Row Imaging Radiology, May 1, 2001; 219(2): 461 - 465. [Abstract] [Full Text]
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D. Fleischmann, G. D. Rubin, D. S. Paik, S. Y. Yen, P. R. Hilfiker, C. F. Beaulieu, and S. Napel Stair-Step Artifacts with Single versus Multiple Detector-Row Helical CT Radiology, July 1, 2000; 216(1): 185 - 196. [Abstract] [Full Text]
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J. E. Roos, J. K. Willmann, D. Weishaupt, M. Lachat, B. Marincek, and P. R. Hilfiker Thoracic Aorta: Motion Artifact Reduction with Retrospective and Prospective Electrocardiography-assisted Multi-Detector Row CT Radiology, January 1, 2002; 222(1): 271 - 277. [Abstract] [Full Text] [PDF]
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