British Journal of Radiology (2004) 77, S27-S38
© 2004 British Institute of Radiology
doi: 10.1259/bjr/25652856
Multislice CT angiography: a practical guide to CT angiography in vascular imaging and intervention
V A Duddalwar, FRCR, MD, MRad
Department of Radiology, Aberdeen Royal Infirmary, Grampian University Hospitals Trust, Foresterhill, Aberdeen AB25 2ZN, UK
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Abstract
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The development of multidetector CT (MDCT) has revolutionized CT angiography (CTA). Not only are new techniques now in the remit of CTA, but all the studies previously performed on single slice or helical CT can now be done with better resolution. The advantage of MDCT relevant to CTA is the ability to acquire high resolution, near isotropic data sets in a shorter acquisition time. Also important is the ability to achieve a longer scanning range in the arterial phase, which has seen the introduction of CTA of the peripheral arterial system. Image processing techniques have also progressed rapidly, with simplification of a previously cumbersome process. The high spatial resolution and relatively non-invasive nature make MDCT angiography a strong and serious competitor to established vascular imaging techniques. The implication is that traditional diagnostic pathways for evaluation of the vascular system have changed.
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Introduction
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The development of multidetector CT (MDCT) scanners has been one of the most important technological advances in CT technology. There has been an exponential increase in the use of MDCT angiography (MDCTA) [1–3]. The cause of this is multifactorial. We do not need to sacrifice high spatial resolution in the z-axis to achieve longer scan length or coverage. More importantly, this is achieved at a faster acquisition rate. Cumbersome data editing and processing tools from the past have now been replaced with dedicated workstations and software that are efficient, quick and clinically orientated [4–6]. This has resulted in examinations such as CT imaging of peripheral vessels, which was not possible even with helical CT, now being in the remit of most MDCT scanners [7]. Examinations such as studies of the aorta that were already being performed can now be done with superior resolution [8].
The development and increasing use of MDCTA will result in changes in workflow patterns in diagnostic and interventional radiology units as well as in surgical departments.
However, with the development of MDCT technology, the radiologist is faced with a bewildering array of image acquisition and reconstruction options. Image quality is critically dependent on contrast medium injection, data acquisition and post-processing technique. In each of these areas, conceptual understanding of the effects of various parameters is necessary for optimization of CT angiography (CTA) studies. In addition, advances in these areas are facilitating improved diagnostic quality and the development of novel applications.
This article looks at practical aspects of MDCTA, including indications (Table 1
), scanning protocols, comparison with other imaging modalities (Table 2), setting up a CTA service and briefly detailing various types of angiography. An understanding of fundamental principles underlying CTA, including CT acquisition, image processing and image display are useful to achieve consistent results. Detailed descriptions of individual pathological conditions are beyond the scope of this article and readers are referred to specialist articles; this article is meant to serve as a practical guide only.
To consistently produce high quality diagnostic examinations, a few general principles are noteworthy. These are applicable to all forms of MDCT angiographic studies.
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Scan protocols
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This is perhaps the most undervalued and overlooked part of the examination. As with all radiology examinations, a detailed, completed request form is absolutely essential. Making sure the area of interest is covered and that the primary diagnostic question is answered are important to prevent a non-diagnostic test. The necessity of pre-contrast scans or delayed scans should be decided beforehand. Having established scanning protocols also ensures reproducibility and a smooth workflow.
Two basic types of protocol are used: (1) high resolution for carotids and visceral vascular beds; and (2) high speed for aorta and peripheral work.
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Pre-contrast scans
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These are not essential for all CTA examinations, but they are still useful in acute conditions to detect the presence of haemorrhage or mural haematoma. Other benefits include deciding the field of coverage and deciding an appropriate site to place the cursor for contrast bolus tracking. The majority of the required information is usually available from a low dose scan, thus limiting radiation exposure. Another useful technique is to use a diagnostic quality topogram, which we use for stent-graft monitoring. This gives a good overview and helps in evaluating the presence of mechanical kinks.
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Contrast medium injection
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An understanding of the pharmacokinetics of contrast medium injection is extremely useful in the application of CTA in routine clinical use. It is perhaps the single most important factor in achieving consistently good results.
The goal of contrast medium injection is to achieve homogeneous "pure arterial" (without venous or tissue contamination) enhancement synchronized with image acquisition. This is in turn dependent on a number of factors such as rate of injection, contrast medium density, cardiac output and blood volume [9, 10].
The tracer kinetic theory has been used to analyse bolus geometry, and this has led to the development of experimental pharmacokinetic models that have helped in designing contrast medium injection protocols [11, 12].
In general, it is important to tailor contrast medium use in CTA depending on patient and investigation variables. A few guiding principles are mentioned here.
(1) Intravenous access: An appropriately sized antecubital vein is the most convenient. In view of the high flow rates needed, ensuring the cannula is not kinked due to the patient's position is important. For neck and upper extremity studies, to decrease the streaking artefact from high density contrast medium in the veins, inject into either the lower limbs or in the arm contralateral to the side of interest.
(2) Saline chaser: Use of a saline chaser serves not only to reduce the amount of contrast medium needed but also prevents streaking artefacts. The saline chaser can be used by either afterloading the contrast medium in a single barrel injector or using one of the double barrel injectors available.
(3) Injection rate: An optimum injection rate is important to achieve homogeneous opacification as well as good opacification of the smaller vessels. The contrast density level and synchronization of the contrast medium injection with image acquisition is critical. The faster that scan technology gets, as with 16-slice MDCT scanners, the less forgiving it is. (a) Monophasic injection: A single static rate of injection is used. On tracing time–arterial attenuation curves there is a short-lived peak. (b) Biphasic injection: This generates a more favourable plateau of contrast medium injection. There is an initial more rapid phase resulting in a peak in the corresponding curve but with a more prolonged plateau. In practical terms this produces a more consistent and reproducible result with less interpatient variation [13]. Most modern pump injectors are capable of handling biphasic and even multiphasic injections.
(4) Timing: There is no place in CTA for guessing the optimal time of enhancement. We use bolus tracking routinely. Another alternative is to use test bolus injections to assess the time for optimum scanning.
(5) Physiological factors: The key factors to remember are: (a) Body size: This relates to proportionate blood volume. In general we use 1.5 ml kg–1 body weight of contrast medium. (b) Cardiac output: In patients with low cardiac output, the peak arterial enhancement is later. Hence, to achieve uniform enhancement it is often useful to place the cursor for bolus tracking at the bottom of the aneurysm. It is important to remember that mean contrast enhancement in patients with high cardiac output is actually less. (c) High concentration contrast medium: With faster scanners, the use of high concentration contrast medium (having >350 mg I ml–1) is useful to achieve a high concentration of iodine in the vessels. It is possible to reduce both the injection rate and the total volume of contrast medium needed if high concentration contrast medium is used [14].
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Post processing (Table 3)
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A MDCT angiographic study easily generates over a thousand axial images. Post processing of these large volume data sets is a challenge. Other core problems with these large data sets are image transfer rates on the system and/or hospital network as well as storage requirements both online and offline. These large data sets are also a challenge for radiologists or physicians who rely on film interpretation. The role of the post-processing workstation is to optimize the diagnostic information to the end user. Using just the axial images leads to loss of much available information. At the same time, however, it is easy to land in a situation of information overload. Post processing prevents both these situations and results in optimization of the information for both diagnosis and presentation. An important concept of MDCTA is that we acquire a volume of data. This is especially important in high resolution studies such as visceral angiography. A combination of optimal use of processing techniques such as volume rendering and of editing techniques allows the radiologist and clinician to interactively explore different aspects of the data set to answer many specific questions that impact on patient management.
One result of the number of new MDCT applications is the constantly evolving workstations. Not only do MDCT manufacturers have their own workstations, there are numerous firms offering stand-alone workstations. Some PACS (picture archiving and communication system) workstations also offer basic post-processing functionality.
An important aspect of workstation post processing is to understand the basics of various techniques. Details of each technique are beyond the scope of this article and interested readers are referred to various excellent specialist articles [15]. Specialist workshops are also a good introduction to post processing. Commonly used techniques are maximum intensity projection (MIP), volume rendering (VR), multiplanar reconstruction (MPR) or curved planar reconstruction (CPR) (Figure 1).
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Figure 1. Examples of post-processing techniques in a patient with ileofemoral disease. (a) Maximum intensity projection, (b) volume rendering and (c) curved planar reconstruction, useful in heavily calcified vessels.
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Maximum intensity projection (MIP)
A ray is projected along the data set in a user-selected direction and the highest voxel value along the ray becomes the pixel value of a two-dimensional MIP image. The resulting images are usually displayed with no surface shading or other devices to help the user appreciate the "depth" of the rendering, making three-dimensional relationships difficult to assess. If there is another high intensity material along the ray through a vessel (such as calcification) the displayed pixel intensity will only represent the calcification and will contain no information from the intravascular contrast medium. This can lead to overestimation of stenosis. Also, normal vessels passing obliquely through a volume can have a "string of beads" appearance. Therefore, MIPs in more than one direction may be needed to evaluate a data set.
Volume rendering (VR)
As the name implies, this technique renders the entire volume of data rather than just surfaces, and so potentially conveys more information than a surface model [16]. A volume data set is analysed interactively using various display algorithms to select and weight voxels to achieve a display that highlights tissues and relationships of interest. Transfer functions are used to map properties such as opacity, brightness, colour and windowing to the voxels in the volume of interest, with all voxels in the volume potentially contributing to the final image. In real-time, the displayed image can be cut and rotated, and transfer functions can be altered. It follows that this needs more powerful processing computers. VR techniques sum the contributions of each voxel along a line from the viewer's eye through the data set. This is done repeatedly to determine each pixel value in the displayed image.
VR algorithms are capable of revealing internal structures that would normally be hidden when using traditional surface rendering techniques. One of the biggest advantages of VR is perspective or depth information.
Multiplanar reconstruction (MPR)
MPR is useful for rapidly reviewing all the information in coronal, sagittal or oblique views. A significant disadvantage is that the structure of interest should lie in one plane. However, an important advantage is the simultaneous parenchymal information, which is important in visceral CTA studies.
Curved planar reconstruction (CPR)
CPRs are useful to analyse individual vessels, especially heavily calcified ones. It is important to recognize that CPR is totally operator dependent, is a single voxel thick tomogram and should be analysed carefully.
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Image storage and display
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Hard copies of images from various reconstructions should be produced to help either the surgeon or the interventionalists during treatment. PACS offers the best solution for image storage and display.
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Clinical applications
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Aorta
CTA has been used to evaluate the aorta since the days of conventional and helical CT. The advantage of MDCT is that the whole aorta can be imaged in the true arterial phase with high spatial resolution [17, 18]. Compared with catheter angiography, CTA is superior in demonstrating mural thrombus, perianeurysmal blood and co-existent non-vascular abdominal disease. It represents a single test that is capable of providing all the information needed for evaluation, treatment planning and follow-up of aortic aneurysms [19] (Figure 2; Table 4). Magnetic resonance angiography (MRA) (3D contrast-enhanced MRA) has a few limitations because it depicts only the lumen and for evaluation of mural thrombus and the vessel wall additional sequences are needed. However, post processing of MRA data sets is easier as only the arterial lumen has high signal and editing of bone and calcium is not an issue.
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Figure 2. Volume rendering image of a patient with a right-sided aneurysmal descending thoracic aorta, aberrant left subclavian artery with an aneurysm at its origin (Komerall's diverticulum) causing an impression on the oesophagus, direct origin of the right common carotid from the aortic arch. A multidetector CT angiogram was the only test needed for complete evaluation.
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While CTA is perhaps the commonest test to evaluate clinically suspected thoracic aortic dissection, other modalities such as transoesophageal echocardiography, MRA and catheter angiography have a significant role. A few disadvantages of CTA in this clinical scenario have been documented [20]. These include occasional failures to opacify the false lumen, and poor demonstration of the complications of Type A dissections such as aortic valvular and coronary involvement. However, the advantages of speed and easy access make MDCTA the investigation of choice in traumatic injury [21].
Post-EVAR monitoring
The Society of Interventional Radiology (SIR) has stated that CT is the gold standard test for monitoring aortic aneurysms treated by EVAR (Table 5). The scan technique is modified by the inclusion of a delayed phase to exclude an endoleak [22, 23].
The significance of an endoleak is that it represents systemic pressures in the native sac and therefore a failure of the stent-graft (Figure 3). The term endotension is used when aneurysmal sac enlargement is demonstrated in the absence of an endoleak.
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Figure 3. Endoleak seen in a patient following surgical repair. Spontaneous resolution noted subsequently.
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Peripheral arterial system
MDCTA can be used to investigate the spectrum of diseases comprising peripheral vascular occlusive disease [7, 24]. This would include patients presenting with either critical limb ischaemia or claudication. The aim is to characterize steno-occlusive disease of inflow, femoral and run-off vessels so as to triage patients into treatment groups (Figures 4–7).
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Figure 4. (a) Thrombus seen within the stent-graft following endovascular aneurysm repair. (b) This extended to cause thrombotic occlusion of one iliac limb, subsequently recovered by thrombolysis and secondary stenting.
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Figure 5. (a) Maximum intensity projection image showing bilateral common iliac stenosis in a patient with bilateral claudication. (b) Digital subtraction angiography image during iliac stenting demonstrates similar disease.
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Figure 6. Post-graft sepsis. Multidetector CT angiography demonstrates occluded graft and developing perigraft collection.
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Figure 7. Aneurysm of the common femoral artery. Multidetector CT angiography demonstrates the relationship to the branches, helping treatment planning.
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This is without doubt the most demanding study on the MDCT scanner and post-processing software. A recent comparative study between MDCTA and catheter angiography revealed that arterial segments distal to occlusions were not seen on catheter angiography but were demonstrated on MDCTA [7].
MRA evaluation of the peripheral arterial tree is an alternative imaging strategy. The most commonly used technique, namely 3D contrast-enhanced MRA, has the following limitations: (a) artefacts/non-visualization of the lumen in the presence of some surgical clips and stents; (b) pseudo-occlusion of tortuous arteries is sometimes a problem if they are not carefully included in the imaging plane; and (c) no bony landmarks are available for surgeons to plan incisions.
Renal CTA
The indications for renal CTA include evaluation of hypertensive patients for renovascular disease, evaluation of potential renal donors, vascular mapping in tumours and selected pelviureteric junction obstructions [25, 26]. Other uses have included assessment following transplant and assessment for renal artery aneurysms or embolism.
CTA is used not as a screening tool in all hypertensive patients but is used in selected patients suspected of having renovascular disease. A venous phase can be added in some cases such as renal donor evaluation. In selected cases, a delayed topogram or scan gives anatomical detail of the pelvicalyceal system and ureters. MRA studies have the ability of time resolved studies, which may provide some beneficial information.
Mesenteric CTA
MDCTA is a relatively non-invasive tool for the visualization of normal vascular anatomy and its variants as well as pathological conditions of the mesenteric vessels [26]. The added advantage is that abdominal organ imaging can be performed in the same study. Depending on the individual clinical scenario, the study may have to be modified to answer specific questions.
It is used in the evaluation of visceral vascular beds such as the liver before and after surgery [27] (Figure 8). It is also extremely useful in the evaluation of both acute and chronic mesenteric ischaemia [28–30]. An important advantage for endovascular treatment is that it highlights stenotic or tortuous vessels that may necessitate a change in access, e.g. brachial artery access (Figure 9). Its exact role in the evaluation of gastrointestinal tract bleeding is being evaluated and should be used selectively in specific scenarios.
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Figure 8. (a) Psuedoaneurysm from a branch of the right hepatic artery (following percutaneous biliary drainage) demonstrated on multidetector CT angiography. (b) Digital subtraction angiography image during coil embolisation of pseudoaneurysm.
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Figure 9. (a) Volume rendering image of two splenic artery aneurysms in a tortuous splenic artery identified on multidetector CT angiography. (b) Digital subtraction angiography image from a selective splenic angiogram during endovascular treatment. The tortuous artery would have needed multiple projections to demonstrate the aneurysms.
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Dosage issues (Table 6)
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Obese patients
Photon starvation leading to excessive image noise is the major problem in these patients. Various steps can be taken to ensure a diagnostic quality scan. The operator should maximize or increase mAs, increase gantry rotation time and use thick slices for the reconstructed images. Also increase iodine dosage and maximize contrast medium flow rate.
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Paediatric patients
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It is especially important to protocol these scans carefully, making sure that the test is definitely indicated. Faster MDCT scanners such as 16-slice MDCT units have tremendous potential advantages in the paediatric patient. Scans times of approximately 5 s per study of the chest or abdomen often eliminate the need for sedation owing to minimal need for patient cooperation. It goes without saying that we must always be aware of radiation dose in these special patients and must minimize dose whilst maximizing the information available from a CT scan.
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Setting up a vascular CT service
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In reality, this service already exists in one form or another in most radiology departments. The introduction of MDCT will enhance the need for formalizing this service. In the author's department this was achieved by:
(1) Review of existing needs and provisions.
(a) An active stent-grafting programme, including selection and monitoring of patients.
(b) Emergency cases such as aortic dissection or rupture.
(c) Evaluation of living related renal donors.
(d) Diagnostic angiographic work, including peripheral and visceral work.
(2) Discussions with referring physicians and surgeons regarding need.
(3) Active involvement of the team of radiographers. In our case this involved additional training for some as well as a change in work patterns.
(4) Setting up protocols.
(5) Audit and feedback.
In departments with a significant vascular case load, such as the author's department, there are definite advantages in having a dedicated vascular CT list.
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The future
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At the moment there is a dearth of published randomized controlled trial data to evaluate the role of MDCTA in various clinical scenarios. However, this is being addressed in various ongoing trials. Small-vessel inflammatory disease also needs further evaluation [31]. In addition, there is promise in the implications of coronary CT data in which the behaviour of atherosclerotic plaques was predicted. If we are able to predict which of the atherosclerotic plaques are more likely to rupture, those patients could be subjected to preventive treatment or aggressive monitoring. If these data are extended and applied in the aorta and peripheral vasculature after validation, a new phase in the role of MDCTA would begin.
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Summary
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MDCTA is now an established diagnostic test in the evaluation of many vascular diseases. To ensure consistent high quality studies, careful selection of parameters and scanning technique is essential. MDCTA provides excellent anatomical detail and this has resulted in a change in the way vascular imaging is acquired non-invasively, resulting in effective triaging of patients into various treatment groups.
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Appendix: Scan protocols
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(All protocols designed for GE LightspeedPlus and should be modified appropriately for other models and manufacturers.)
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Acknowledgments
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The author wishes to acknowledge the help of J S Watson and all the CT radiographers at Aberdeen Royal Infirmary, and Prof. J Weir, A P Thorpe and J K Hussey from the Department of Radiology, Aberdeen Royal Infirmary.
Received for publication May 13, 2003.
Revision received August 20, 2003.
Accepted for publication August 26, 2003.
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Abstract
Introduction
