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Vascular and Interventional Radiology |
1 From the Departments of Radiology (C.C., F.F., A.L., A.N., M.B., F.P., M.D., R.P.) and Experimental Medicine and Pathology (I.N.), University of Rome "La Sapienza," Viale Regina Elena 324, 00161 Rome, Italy. From the 2001 RSNA scientific assembly. Received July 26, 2002; revision requested September 10; final revision received September 8, 2003; accepted October 14. Address correspondence to C.C. (e-mail: carlo.catalano@uniroma1.it).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Fifty patients with peripheral arterial occlusive disease were evaluated with multi–detector row CT angiography and DSA. Arteries depicted at CT angiography and DSA were graded separately for degree of stenosis as 23 anatomic segments (infrarenal aorta, right and left common iliac artery, internal iliac artery, external iliac artery, common femoral artery, superficial femoral artery, deep femoral artery, popliteal artery, anterior tibial artery, tibioperoneal trunk, posterior tibial artery, and peroneal artery). Grades included the following: 1, normal patency; 2, moderate (
50%) stenosis; 3, focal severe (>50%) stenosis; 4, multiple severe stenoses; and 5, occlusion. Three readers independently interpreted the images, and statistical analysis was performed. The results of image interpretation were evaluated for strength of agreement by using Cohen 
statistics. On the basis of consensus readings, sensitivity, specificity, and accuracy for detection of stenotic lesions were calculated, with findings at DSA used as the reference standard.
RESULTS: Substantial to almost perfect interobserver agreement was achieved in all cases. At DSA, 349 diseased segments were found among the 1,137 segments evaluated. Sensitivity, specificity, and accuracy, based on a consensus reading of multi–detector row CT angiograms, were 96%, 93%, and 94%, respectively. A statistically significant difference (P < .05) between DSA and multi–detector row CT angiography was present only in arteries graded 1 or 2. Interobserver agreement was almost perfect among the three readers for treatment recommendations based on findings at CT angiography and DSA.
CONCLUSION: Multi–detector row CT angiography appears consistent and accurate in the assessment of patients with peripheral arterial occlusive disease.
© RSNA, 2004
Index terms: Angiography, comparative studies, 92.1222, 98.1222 • Arteries, CT, 92.12916, 92.12917, 98.12916, 98.12917 • Arteries, extremities, 92.721, 98.721 • Computed tomography (CT), angiography, 92.12916, 92.12917, 98.12916, 98.12917
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Therefore, in the evaluation of patients with peripheral arterial occlusive disease, DSA, although invasive and expensive, was and is still considered the reference standard (4). DSA, however, carries a risk of complications, which should be considered in imaging of a population in which an increasing number of patients are affected by atherosclerotic disease that is potentially treatable with a percutaneous approach (5–7). Noninvasive alternatives for accurate depiction of pelvic and runoff vessels are therefore desirable.
The recent introduction into clinical practice of multi–detector row spiral CT with simultaneous acquisition of four channels has had a substantial effect on CT angiography by enabling high-spatial-resolution imaging of large volumes with excellent visualization of small branches and by permitting a reduction in the dose of the iodinated contrast agent (8–10). A previous study showed the feasibility of multi–detector row CT angiography of runoff vessels with excellent arterial enhancement and without substantial venous enhancement (11).
The purpose of our study was to compare multi–detector row spiral computed tomographic (CT) angiography with digital subtraction angiography (DSA) in evaluating the infrarenal aorta and lower- extremity arterial system.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The patients were referred to the angiography service by multiple vascular surgeons. None of the patients had metallic prosthetic joints, and none had previously undergone percutaneous vascular intervention or surgical bypass. All patients included in the study had normal renal function. The grade of lower-extremity arterial disease in each patient had been defined according to Rutherford and Becker (12). Three patients had grade I, 24 had grade II, and 23 had grade III disease (Table 1).
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In all patients, both examinations were successfully carried out; no complications related to contrast medium injection were observed. No patients, even those with advanced occlusive disease (Rutherford and Becker grade III), reported any discomfort during or after multi–detector row CT.
Digital Subtraction Angiography
In all patients, DSA was performed with a cardiovascular imaging system (Integris V5000; Philips Medical Systems, Best, the Netherlands) by two radiologists (C.C. and M.B.) who were experienced in vascular and interventional radiology. A transfemoral approach was used in 43 patients (29 right and 14 left femoral punctures), and a left transaxillary approach was used in seven patients in whom transfemoral access could not be achieved (in two of these seven patients, access via the right femoral artery was initially attempted). In all patients, a 5-F pigtail catheter was positioned in the juxtarenal aorta for anteroposterior and lateral aortography. The catheter was then lowered to a position just above the aortic bifurcation for anteroposterior and oblique imaging of the pelvic vessels and anteroposterior imaging of the runoff vessels. Runoff vessels were examined sequentially at four to five levels by using separate contrast medium injections. A nonionic contrast agent (iomeprol [350 mg of iodine per milliliter], Iomeron; Bracco, Milan, Italy) was used in all patients. For each injection, 20 mL of the contrast agent was injected at a rate of 20 mL/sec with the catheter positioned at the level of the juxtarenal aorta, and at a rate of 10 mL/sec with the catheter positioned at the aortic bifurcation. A total volume of 140–160 mL of the iodinated contrast agent was administered to each patient. In the 23 patients who had Rutherford and Becker grade III disease, dedicated imaging of the pedal vessels was performed with selective femoral injections, which required administration of an additional 20 mL of the contrast agent.
Multi–Detector Row CT Angiography
Multi–detector row CT angiography was performed in all patients by using a multi–detector row spiral CT scanner (Volume Zoom; Siemens, Forchheim, Germany) with a 0.5-second gantry rotation time. Patients were positioned supine with their feet first. Patients’ feet were secured at a slight degree of internal rotation to separate the tibia from the fibula and, consequently, the trifurcation vessels from the bones. After the acquisition of a 1,024-mm initial topogram, the acquisition volume was repositioned for examination of an arterial segment extending from the diaphragm to the feet. The volume varied in length, depending on the height of the patient.
An 18-gauge intravenous cannula was inserted into a superficial vein in the antecubital fossa, forearm, or dorsum of the hand. Multi–detector row CT angiography was performed after intravenous injection with an automatic power injector (EnVision CT; Medrad, Indianola, Pa) of 140 mL of the contrast medium at a flow rate of 4 mL/sec to provide a bolus duration of 35 seconds. A high-iodine- concentration nonionic contrast agent (iomeprol 400 mg iodine per milliliter; Bracco) was used in all patients.
Multi–detector row CT angiography was performed by using 4 x 2.5-mm collimation, 3-mm section thickness, table feed of 15 mm per gantry rotation (30 mm/sec), and gantry rotation time of 0.5 second. X-ray tube voltage was 120 kV, and amperage was 130 mAs. With this protocol, the weighted CT dose index was 12.22 mGy. Sections were reconstructed with a 3-mm interval. Raw data were stored so that, if necessary, further reconstructions could be performed with a shorter interval (1.5 mm). A standard delay time of 28 seconds was used in all patients, and no determination was made of the actual circulation time. The entire examination, including reconstruction of image data, took 7–10 minutes, with venous access achieved in a preparation room.
Image Analysis
All CT angiograms were analyzed with real-time interactivity by using a dedicated workstation (Kayak XU 800; Hewlett-Packard, Palo Alto, Calif) with three-dimensional image rendering software (Vitrea 2.6; Vital Images, Plymouth, Minn), with which all three independent readers had experience of at least 6 months. No predefined reconstructions, planes, or projections were performed by radiologic technologists. Three-dimensional analysis was performed directly by the readers, who took approximately 15–20 minutes to interpret each case. For diagnostic purposes, bone segmentation was not considered necessary by any of the readers, but nevertheless it was routinely performed and hard copies were printed to provide vascular surgeons with anatomic reference images. Rapid scrolling through the transverse images was performed by all three readers as the first step in the review process for all multi–detector row CT angiographic examinations. The reader then could choose different planes of examination and could apply the various reconstruction algorithms (multiplanar reformation, maximum intensity projection [MIP], thin MIP, and/or volume rendering) available at the workstation. By using this approach, the reader could display and select any portion of the scan volume interactively, generating any plane or perspective thought useful.
The arteries were separately evaluated as 23 anatomic segments on DSA images and on multi–detector row CT angiograms. Each arterial segment was assigned one of five possible grades based on the degree of stenosis: 1, normal patency; 2, moderate disease (50% stenosis); 3, focal severe disease (>50% single stenosis); 4, diffuse severe disease (>50% multiple stenoses); or 5, occlusion. Readers were given a chart of 23 vascular anatomic segments (infrarenal aorta, right and left common iliac artery, internal iliac artery, external iliac artery, common femoral artery, superficial femoral artery, deep femoral artery, popliteal artery, anterior tibial artery, tibioperoneal trunk, posterior tibial artery, and peroneal artery), each of which was to be assigned one of these five stenosis grades.
Multi–detector row CT angiograms and DSA images were independently evaluated by three readers from the same institution, who had different degrees of experience in CT vascular imaging and angiography. Reader 1 (C.C., with 6 years of experience) and reader 2 (M.B., with 8 years of experience) were staff members in vascular radiology, and reader 3 was a fellow in vascular radiology (F.F., with 2 years of experience). Prior to this study, to gain experience with the interpretation procedures, each reader independently evaluated DSA images and multi–detector row CT angiograms obtained for comparison in 10 patients who had peripheral arterial occlusive disease and who were not included in this study. In this study, the interpretation of images from each modality was performed in a blinded manner so that the reader was not aware of the results of interpretation of images from the other modality and of interpretations by other readers. The interval between the readings of multi–detector row CT angiograms and of DSA images was 4–5 weeks; two readers started with the multi–detector row CT angiograms, and the other reader began with the DSA images. Multi–detector row CT angiograms were interpreted at a dedicated workstation, at which readers were free to use all available reconstruction algorithms and to scroll through the transverse images.
A treatment recommendation was independently determined in a blinded manner by the readers on the basis of DSA images and multi–detector row CT angiograms. The eight treatment options included no treatment, percutaneous transluminal angioplasty with or without an endovascular stent, percutaneous transluminal angioplasty and surgical bypass, iliac arterial bypass, femoral arterial bypass with one of three possible surgical procedures (bypass above the knee, below the knee, or distal), and amputation. As a general rule, percutaneous transluminal angioplasty and endovascular stent insertion were recommended for focal disease, particularly for iliac and femoral artery stenosis or occlusion of less than 20 mm in length. Longer occlusions and diffuse disease were treated with surgical bypass.
Statistical Analysis
The results of the image interpretations were entered in a database (Excel for Office 2000; Microsoft, Redmond, Wash) and evaluated for strength of interobserver agreement among the three readers by using Cohen statistics, which were calculated with statistical software (SPSS 8.0 for Windows; SPSS; Chicago, Ill), to determine poor ( < 0.01), slight ( = 0.01–0.20), fair ( = 0.21–0.40), moderate ( = 0.41–0.60), substantial ( = 0.61–0.80), and almost perfect ( = 0.81–1.00) agreement beyond that of chance alone.
Twenty-four vascular segments about which there was grading disagreement between different readers were re-evaluated for a final consensus interpretation. If there was one different interpretation among three, consensus was considered the interpretation of the two concordant readers. On the basis of consensus readings, sensitivity, specificity, and accuracy for detection of stenotic lesions were calculated by using DSA findings as the standard of reference.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In all other patients, arterial enhancement was satisfactory with use of the standard delay time. There were 13 patients with unilateral severe diffuse disease and asymmetric flow in the popliteal and calf vessels (Fig 1), but these conditions did not impair image quality or prevent comparison between the two techniques, which was performed for all 1,137 segments.
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= 0.81–1.00) at the level of the common iliac, common femoral, deep femoral, superficial femoral, and popliteal arteries and was substantial ( = 0.61–0.80) at the level of the tibioperoneal trunk and posterior tibial arteries. Agreement was substantial to almost perfect ( = 0.61–1.00) in all other segments.
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= 0.81–1.00) at the level of the aorta, superficial femoral artery, and popliteal artery. For all observer combinations, agreement was substantial ( = 0.61–0.80) at the level of the posterior tibial and peroneal arteries. Agreement was substantial to almost perfect ( = 0.61–1.00) in all other segments.
DSA versus CT Angiography
At consensus reading, 1,137 segments were identified on both multi–detector row CT angiograms and DSA images. On DSA images, 349 diseased segments (30.7%) were identified: 95 with moderate stenosis, 26 with focal severe stenosis, 53 with diffuse severe stenoses, and 175 with occlusion. In 75 segments (48 of which were considered normal at DSA but were diagnosed as mildly stenosed at multi–detector row CT), the degree of stenosis was overestimated at multi–detector row CT angiography by one grade; in 12 segments, the degree of stenosis was overestimated by two grades. The degree of stenosis was underestimated by one grade in 20 segments, by two grades in one segment, and by three grades in one segment (Table 3). A statistically significant difference (P < .05) between DSA and multi–detector row CT angiography was found only in segments graded 1 or 2. In all other cases, there was no statistically significant difference between DSA and multi–detector row CT angiography.
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value of 0.812 (almost perfect agreement). If one considers the aortoiliac segments as a separate group (Fig 2), the sensitivity of multi–detector row CT angiography was 95%, with a specificity of 90% and accuracy of 92%; the value was 0.775. In the femoral tract (common, superficial, and deep femoral arteries) (Fig 3), the sensitivity of multi–detector row CT was 98%, the specificity was 96%, and the accuracy was 97%, with a value of 0.897. In the distal tract (popliteal artery, tibioperoneal trunk, anterior and posterior tibial arteries, and peroneal arteries) (Fig 4), sensitivity, specificity, and accuracy were 96%, 93%, and 94%, respectively, with a value of 0.774.
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= 0.929).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Catheter-based DSA has remained the standard of reference for the evaluation of peripheral ischemia. Nevertheless, given the invasiveness, cost, and frequency of complications of DSA, a noninvasive alternative technique for evaluating atherosclerosis, stenosis, and occlusion in patients with peripheral arterial disease would be of clinical value.
The usefulness of spiral CT for demonstrating vascular diseases has been well documented since its introduction in the early 1990s. Throughout the world, CT angiography has replaced catheter-based angiography for clinical assessment of the aorta and its branches (15,16). Nevertheless, because of the limitations in scanning speed, imaging of the entire runoff with sufficient spatial resolution was not possible with single-section spiral CT scanners (17–19).
Multi–detector row spiral CT offers substantially greater volumetric coverage, with a speed eight times greater than that at single-section spiral CT, as well as excellent longitudinal resolution and near-isotropic voxels. The application that has benefited most from the development of multi–detector row spiral CT is CT angiography (20).
Rubin et al (11) demonstrated the feasibility of high-spatial-resolution imaging of the runoff vessels with multi–detector row CT angiography. Having completed a preliminary investigation to define the optimal parameters of image acquisition and contrast medium injection, and on the basis of a study by Macari et al (21), we decided in this study to use a fixed delay time of 28 seconds and a standard amount of 140 mL of an iodinated contrast agent administered at a flow rate of 4 mL/sec in all patients. In all patients, this strategy provided a diagnostic examination, with no instances of poor arterial enhancement. Although several patients were examined who had unilateral stenotic or occlusive disease with asymmetric flow between the two limbs, almost all arterial segments were successfully visualized; in only one patient, who had occlusion of the iliac axis and common femoral artery, the infrapopliteal vessels of the diseased limb were not well depicted because of slow flow and were excluded from the study. In none of the patients was it necessary to repeat the examination because of poor unilateral or bilateral enhancement. Our imaging protocol provided an image acquisition rate of 3 cm per second, which allowed us to limit the amount of iodinated contrast agent (140 mL) administered, while achieving good enhancement of the distal vessels. In this respect, two advantages of multi–detector row CT angiography over catheter-based DSA are the superior depiction of all collateral vessels and the excellent distal arterial enhancement even in patients with occlusion of the infrarenal aorta and/or both iliac axes. Regarding venous enhancement, although it has been demonstrated that optimal lower-extremity venous enhancement occurs after approximately 200 seconds (22), the veins in a few patients in our series were seen much earlier, during the arterial phase. A retrospective analysis of these cases showed that all of these patients had advanced ischemic disease with cutaneous trophic lesions. Nevertheless, in none of the patients did venous enhancement impair the diagnostic quality of the examination or the three-dimensional reconstructions.
Image analysis was performed at a dedicated workstation by using a three-dimensional real-time interactive approach that consisted of rapid scrolling through the transverse source images, followed by three-dimensional reconstruction of image data with various algorithms. This approach, although it was time consuming in the beginning, allowed attentive analysis and obviated routine bone segmentation, which is also time consuming. Three-dimensional image postprocessing performed by radiologic technologists has been successful at some institutions, but we and others believe (23) that real-time interactivity enables optimal use of the radiologist’s time. In our experience, bone segmentation is performed mainly for hard-copy display of multi–detector row CT angiograms, if a real-time approach is not feasible.
One of the questions we sought to answer was whether multi–detector row CT angiography could replace DSA. The results of this study show that, like single–detector row spiral CT in the assessment of other vascular regions, multi–detector row CT is highly accurate in the assessment of peripheral vascular disease, independent of the grade of ischemia. The level of interobserver agreement was high for the interpretation of both multi–detector row CT angiograms and DSA images; all three readers in this study were experienced in vascular imaging and angiography. Among the vascular regions with the lowest level of interobserver agreement at interpretation of both DSA images and multi–detector row CT angiograms were the calf vessels, particularly the peroneal artery, because of differing interpretations of the vessel extent.
For all readers, there was a tendency to overestimate the degree of stenosis, whereas instances of underestimation were few. Nevertheless, the only statistically significant difference between readers was found in differentiation between normal and mildly diseased arteries, and no change in therapeutic approach resulted from the erroneous interpretations. In fact, interobserver agreement was almost perfect even with regard to treatment recommendations. It must also be emphasized that, even at retrospective review, the presence at multi–detector row CT angiography of minor parietal alterations that were not demonstrated at DSA was confirmed in most instances, particularly at the level of the iliofemoral segments. In our experience, there was a tendency with multi–detector row CT angiography to overestimate slight parietal alterations; however, as pointed out in previous studies, the visualization of vessel walls that is intrinsic to transverse image acquisition is an important advantage of CT, not only in comparison with DSA but also relative to other noninvasive imaging modalities, such as contrast-enhanced magnetic resonance (MR) angiography. The analysis of transverse sections together with three-dimensional reconstructions in this study provided superior information about occlusions secondary to aneurysmal disease, particularly with regard to the morphology of plaques—information that is useful in treatment planning. It would be interesting to evaluate whether the excellent depiction of vessel wall morphology provided by multi–detector row CT can help to predict vessel wall disease or patency of distal bypass grafts after they are formed (24).
Discordance also was observed among the three readers in the differentiation of focal severe stenosis from diffuse severe stenoses, especially in distal vessels. The main cause of difficulty in differentiation between the two was the presence of circumferential and heavy parietal diffuse calcifications, which may have led to underestimation of the degree and extent of stenosis, particularly in small-caliber vessels. In this respect, although the use of 2.5-mm collimation and 3-mm contiguous sections provided satisfactory results in most cases, it is advisable to store all raw data for use in performing further reconstructions at thinner intervals, if necessary, to improve the spatial resolution and accuracy in distal smaller branches. In the presence of calcified plaques, real-time interaction with the three-dimensional data set provided better results. Our experience suggests that all of the available reconstruction algorithms should be used, because each may provide different information. The exclusive use of MIP, thin MIP, and volume rendering may impair the quantification of stenosis, particularly if heavy parietal calcifications are present. Although the analysis of transverse images may be time consuming, rapid scrolling through selected transverse sections (if not through all of them), combined with evaluation of multiplanar reformations, can be helpful for differentiating calcifications from true lumen and determining the degree of stenosis.
A limitation of our study is that we did not include the dorsalis pedis and plantar arteries in the comparative evaluation, although the foot is routinely examined with multi–detector row CT angiography. Selective injections for imaging of the pedal vessels were performed during DSA only in patients with critical ischemia and tissue loss.
Two major limitations of multi–detector row CT angiography for the evaluation of patients with peripheral arterial occlusive disease are the use of ionizing radiation and the use of iodinated contrast agents. Regarding the first of these, it has been recently noted (25) that the radiation dose is not of great concern in patients with peripheral arteriopathy, who are typically elderly, and that the dose at multi–detector row CT compared with that at DSA is substantially lower (11). Furthermore, it might be possible to reduce the radiation dose to the patient by optimizing the acquisition protocol, as has been done at multi–detector row CT in other parts of the body (26). Regarding the use of iodinated contrast agents, it must be considered that some patients have poor renal function and may not tolerate such contrast agents. Nevertheless, the nephrotoxicity of nonionic contrast agents is substantially lower than that of ionic contrast agents, and the administration of iodinated contrast agents can be considered safe and well tolerated, even in a high-risk population (27). Furthermore, the amount of iodinated contrast agent used in this study was substantially less than that used in previous studies, and further increases in speed offered by new multi–detector row CT scanners will allow the use of smaller amounts.
It is difficult to determine what the role of multi–detector row CT angiography should be, compared with that of contrast-enhanced MR angiography. Although the latter presents several advantages, such as the use of nonionizing radiation and nonnephrotoxic contrast agents (28), multi–detector row CT currently has superior spatial resolution compared with that of MR angiography, and continued rapid improvement in this area is expected. In addition, the diffusion of multi–detector row spiral CT scanners is taking place more rapidly than is that of high-field-strength MR imagers with the software and hardware needed to perform optimal runoff MR angiography.
In conclusion, although multi–detector row CT angiography of the aorta and lower-extremity arteries is in its infancy, the results of this study demonstrate that the technique is highly accurate and reproducible and has potential to substitute in most cases for DSA.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Author contributions: Guarantors of integrity of entire study, C.C., R.P.; study concepts, C.C., A.L.; study design, C.C.; literature research, M.D., F.P.; clinical studies, C.C., F.F., A.N.; data acquisition, A.N., M.D.; data analysis/interpretation, C.C., F.F., M.B.; statistical analysis, I.N., C.C., F.F.; manuscript preparation, C.C., A.L.; manuscript definition of intellectual content, C.C., R.P.; manuscript editing, C.C., A.N.; manuscript revision/review, C.C., A.N., F.F., I.N.; manuscript final version approval, C.C.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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R. Ouwendijk, M. C. J. M. Kock, K. Visser, P. M. T. Pattynama, M. W. de Haan, and M. G. M. Hunink Interobserver Agreement for the Interpretation of Contrast-Enhanced 3D MR Angiography and MDCT Angiography in Peripheral Arterial Disease Am. J. Roentgenol., November 1, 2005; 185(5): 1261 - 1267. [Abstract] [Full Text] [PDF]
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 M. M. Miller-Thomas, O. C. West, and A. M. Cohen Diagnosing Traumatic Arterial Injury in the Extremities with CT Angiography: Pearls and Pitfalls RadioGraphics, October 1, 2005; 25(suppl_1): S133 - S142. [Abstract] [Full Text] [PDF]
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R. Ouwendijk, M. de Vries, P. M. T. Pattynama, M. R. H. M. van Sambeek, M. W. de Haan, T. Stijnen, J. M. A. van Engelshoven, and M. G. M. Hunink Imaging Peripheral Arterial Disease: A Randomized Controlled Trial Comparing Contrast-enhanced MR Angiography and Multi-Detector Row CT Angiography Radiology, September 1, 2005; 236(3): 1094 - 1103. [Abstract] [Full Text] [PDF]
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 G H Roditi and G Harold Magnetic resonance angiography and computed tomography angiography for peripheral arterial disease Imaging, August 1, 2004; 16(3): 205 - 229. [Abstract] [Full Text] [PDF]
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