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CT Angiography of Peripheral Arterial Disease

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CT Angiography of Peripheral Arterial Disease Review Articles CT Angiography of Peripheral Arterial Disease Dominik Fleischmann, MD, Richard L. Hallett, MD, and Geoffrey D. Rubin, MD Lower-extremity computed tomographic (CT) angiography (ie, peripheral CT angiography) is increasingly used to evaluate patients with peripheral arterial disease. It is therefore increasingly important for all vascular specialists to become familiar with the strengths and limitations of this new technique. The aims of this review are to explain the principles of scanning and injection technique for a wide range of CT scanners, to explain and illustrate the properties of current image postprocessing tools for effective visualization and treatment planning, and to provide an overview of current clinical applications of peripheral CT angiography. J Vasc Interv Radiol 2006; 17:3–26 Abbreviations: CPR ϭ curved planar reformation, DSA ϭ digital subtraction angiography, MIP ϭ maximum intensity projection, MPR ϭ multiplanar reforma- tion, 3D ϭ three-dimensional, VR ϭ volume reconstruction ALTHOUGH computed tomographic it is increasingly important to be famil- ning protocol programmed into the (CT) imaging of lower-extremity arter- iar with this latest vascular imaging scanner, peripheral CT angiography is a ies has been attempted with single– technique, to know its strengths and very robust technique for elective and detector row scanners (1–5), it was not limitations, and, most importantly, to emergency situations. When patients before the introduction of multiple– learn how to read and interpret the are mobile, the study can easily be per- detector row CT that adequate resolu- large CT angiographic data sets and formed in 10–15 minutes of room time. tion imaging of the entire inflow and their reformatted images for clinical In general, peripheral CT angiogra- runoff vessels became possible with a decision making and treatment plan- phy acquisition parameters follow single acquisition and a single intrave- ning. those of abdominal CT angiography. nous contrast medium injection (6). The organization of this review re- Unless automated tube current modu- With increasing availability of multi- flects three interrelated objectives. lation is available, a tube voltage of ple–detector row CT scanners, periph- First, we describe the technical princi- 120 kV and a maximum tube amper- eral CT angiography has gradually en- ples of image acquisition and contrast age of 300 mA (depending on the scan- tered clinical practice (7–11), and as a medium injection parameters for a ner) is used for peripheral CT angiog- result of the concomitant rapid evolu- wide range of currently available mul- raphy, which results in a similar tion of CT scanner technology, high- tiple–detector row CT systems. The radiation exposure and dose (12.97 resolution imaging of the peripheral level of detail should allow the diag- mGy, 9.3 mSv) as abdominal CT an- vasculature has become routinely pos- nostic imager to develop his or her giography (7). Breath-holding is re- sible. own scanner-specific peripheral CT quired only at the begining of the CT For the vascular and interventional angiography acquisition and injection acquisition through the abdomen and radiologist, but also for the vascular protocol. Next, we will review the pelvis. Lower amperage (and/or volt- surgeon and cardiovascular specialist, properties of different visualization age) can and should be used in pa- techniques for extracting the relevant tients with low body mass index. In findings and explain how they are in- obese patients, tube voltage and tube From the Cardiovascular Imaging Section, Depart- terpreted. Finally, we will discuss the current often need to be increased. A ment of Radiology, Stanford University Medical accuracy and the practical application medium to small imaging field of view Center, 300 Pasteur Drive, S-072, Stanford, Califor- of CT angiography within the context (with the greater trochanter used as a nia 94305-5105 (D.F., R.L.H., G.D.R.); and Depart- of various clinical situations. bony landmark) and a medium to soft ment of Angiography and Interventional Radiology, Medical University of Vienna, Waehringer Guertel reconstruction kernel are generally 18-20, A-1090, Vienna, Austria (D.F.). Received July used for image reconstruction. 27, 2005; accepted October 8. Address correspon- SCANNING TECHNIQUE dence to D.F.; E-mail: [email protected] Peripheral CT angiograms can be None of the authors have identified a conflict of SCANNING PROTOCOL interest. obtained with all current multiple–de- tector row CT scanners (ie, four or One or more dedicated peripheral © SIR, 2006 more channels). No special hardware CT angiographic acquisition and con- DOI: 10.1097/01.RVI.0000191361.02857.DE is required. With a standardized scan- trast medium injection protocol(s) 3 4 • CT Angiography of Peripheral Arterial Disease January 2006 JVIR should be established for each scanner times, the detector configuration is and programmed into the scanner. A usually set to 4 ϫ 2.5 mm. As a result, full scanning protocol consists of (i) the thinnest effective section thickness the digital radiograph (“scout” image achievable with these scanners is ap- or “topogram”), (ii) an optional non- proximately 3 mm. With overlapping enhanced acquisition, (iii) one series image reconstruction every 1–2 mm, for a test bolus or bolus triggering, (iv) these “standard-resolution” data sets the actual CT angiography acquisition are adequate for visualizing the aor- series, and (v) a second optional “late- toiliac and femoropopliteal vessels, phase” CT angiography acquisition and also provide enough detail to as- (initiated only on demand) in the sess the patency of crural and pedal event of nonopacification of distal ves- arteries if vessel calcification is absent sels (Fig 1). or minimal. Four-channel CT therefore provides adequate imaging in patients Patient Positioning and Scanning with intermittent claudication, in Range acute embolic disease (Fig 2), aneu- rysms, anatomic vascular mapping, The patient is placed feet-first and and also in the setting of trauma. Such supine on the couch of the scanner. To standard-resolution data sets may not keep the image reconstruction field of be fully diagnostic when visualization view small, and also to avoid off-cen- of small arterial branches (ie, crural or ter stair-step artifacts (12), it is impor- pedal) is clinically relevant, such as in tant to carefully align the patient’s legs patients with critical limb ischemia and feet close to the isocenter of the and predominantly distal disease, no- scanner. Tape may be required to hold tably in the presence of excessive arte- a patient’s knees together. Although rial wall calcifications. If higher reso- cushions can be used to stabilize the lution imaging is required and if the extremities for the patient’s comfort, clinical situation permits a smaller an- large cushions under the knees should atomic coverage area (eg, limited to not be used so the field of view can be the legs or to popliteal to pedal vessels kept small. Also, as in conventional an- only) exquisite high-resolution imag- giography, excessive plantar flexion of ing can also be achieved with four- the feet is avoided to prevent an artifac- channel systems with 4 ϫ 1-mm or 4 ϫ tual stenosis or occlusion of the dorsalis 1.25-mm detector collimation (7) pedis artery (ie, “ballerina sign” [13]). within acceptable acquisition times. The anatomic coverage extends from the T12 vertebral body level (to Eight-channel CT include the renal artery origins) prox- ϫ imally through the patient’s feet dis- Figure 1. Digital CT radiograph for pre- A detector configuration of 8 1.25 tally (Fig 1). The average scan length is scribing peripheral CT angiography. The mm permits anatomic coverage of the between 110 cm and 130 cm. Smaller patient’s legs and feet are aligned with the entire peripheral arterial tree within scan ranges or a smaller field of view long axis of the scanner. Scanning range the same scan time as a 4 ϫ 2.5-mm (ie, one leg only) may be selected in (from T12 through the feet) and reconstruc- four-channel CT acquisition at sub- specific clinical situations. tion field of view (determined by the stantially improved resolution. Images greater trochanters; arrows) are indicated with a nominal section thickness of by the dotted line. A second optional CT 1.25 mm, reconstructed at 0.8 mm (ie, Image Acquisition and angiography acquisition is prescribed for Reconstruction Parameters the crural/pedal territory (dashed line). high resolution) can routinely be ac- quired. Crural and even pedal arteries The choice of acquisition parame- can be reliably identified with use of ters (ie, detector configuration/pitch) these settings. With faster gantry rota- and the corresponding reconstruction nel General Electric CT scanners (GE tion speed (0.5 sec/360° rotation) and parameters (ie, section thickness/re- Medical Systems, Milwaukee, WI). De- maximum pitch, eight-channel CT al- construction interval) depends largely tector configuration is denoted as num- lows for extended volume coverage, on the type and model of the scanner. ber of channels times channel width (eg, such as to visualize the entire thoracic, Table 1 provides an overview of pe- 4 ϫ 2.5 mm); section thickness and re- abdominal, and lower-extremity arter- ripheral CT angiography acquisition construction interval are expressed as a ies within a single acquisition (Fig 3). parameters for a wide range of mul- ratio, eg, 3 mm/1.5 mm. tiple–detector row CT scanners, and Sixteen-channel
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