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Potential clinical and economic

benefits of low-contrast-dose
CT angiography
Shawn D. Teague, MD, David I. Rosenblum, DO, Mark E. Olszewski, PhD,
Ekta Dharaiya, MS, and Robert Popilock, BS, RTR

T
he evolution of multidetector in most vascular territories.2,3 Despite other causes, and it is the third most com-
computed tomography (MDCT) the growing acceptance of this technol- mon cause of hospital-acquired acute
throughout the past decade has ogy, the rapid rate of procedure growth renal failure.8,9 Prevention of CIN has
established its position as the workhorse has led to renewed concerns regarding been the subject of many studies10; but the
of radiology. In addition to facilitating both the radiation dose4-7 and the development of new contrast formula-
faster and improved diagnoses in the rou- amount of intravenous contrast deliv- tion,11,12 injection technique,13 and pre-
tine examinations—such as thoracic, ab- ered6,7 to patients undergoing CTA. treatment paradigm,14 strategies to
dominal, pelvic, brain, neck, and spine— Minimizing patient radiation dose is prevent CIN are implemented nonuni-
that make up >85% of annual CT of paramount concern when using formly15 and have shown varied results.16
exams,1 this evolution has sparked a MDCT. As MDCT procedures have It is well-known that vessel visual-
surge in vascular imaging procedures, grown, studies have shown that CT is ization in CTA benefits from higher
such as CT angiography (CTA). an increasing source of radiation expo- contrast volumes, concentrations, and
From 2004 to 2007 alone, the number sure,4 and attempts have been made to injection rates;17,18 however, the risk of
of annual CTA procedures in the United estimate the increase in cancer risk due CIN increases with increased contrast
States more than doubled to 4.7 million.1 to CTA procedures.5 Imaging equip- volume.9,16 Studies using earlier genera-
The concurrent increase in the number ment vendors have made progress in tion MDCT scanners evaluated the pos-
of sites regularly performing CTA pro- the area of radiation dose management sibility of reducing the contrast volume
cedures, from 44% to 67% in the same with the introduction of novel technolo- necessary for various types of CTA
time period,1 further supports the adop- gies, such as prospective electrocardio- examinations,19-22 but it may be possible
tion of MDCT as the noninvasive mo- graphic (ECG)-gating with advanced to consistently decrease contrast vol-
dality of choice for imaging the anatomy algorithms to handle cardiac arrhyth- umes across a wider patient population.
mias, improved beam filtration technol- Efforts to further reduce contrast vol-
Dr. Teague is an Assistant Professor of ogy, and dose-reducing collimators. ume per patient study may reduce the
Radiology, Department of Radiology, Concurrent efforts are underway across risk of CIN and provide institutions
Indiana University School of Medicine, the industry and in academia to provide with an overall economic benefit.
Indianapolis, IN. Dr. Rosenblum is Vice recommendations for the responsible This article details the clinical and
Chair, Department of Radiology, and imaging of pediatric patients.6,7 economic benefits of reduced contrast
Director, Interventional Radiology, At the same time, the amount of con- doses made possible by new CT scanner
MetroHealth Medical Center, and Assis-
trast media delivered to a patient is also technology that is enhanced for speed,
tant Professor of Radiology, Case West-
of utmost concern due to the risk of com- power, and coverage. This combination
ern Reserve University, Cleveland, OH.
Dr. Olszewski is a Research Scientist, plications, particularly contrast-induced of technologic advances may enable
Ms. Dharaiya is a Research Scientist, nephropathy (CIN). Contrast-induced high-quality imaging of all pa-tients
and Mr. Popilock is a Product Manager, nephropathy is defined as acute renal fail- with a consistent reduction in contrast
Computed Tomography Clinical Science, ure occurring within 48 hours of expo- volume of ≥35%, while maintaining
Philips Healthcare, Cleveland, OH. sure to intravascular radiographic con- image quality. Finally, the authors pro-
trast material that is not attributable to vide an economic analysis of potential

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LOW-CONTRAST-DOSE CTA

Table 1. CT angiography scan and contrast injection


protocols for 64- and 256-slice CT scanners
Protocol 64-slice 256-slice
kV 120 120
Field of view (mm) 300–400 300–400
Slice thickness (mm) 0.9 0.9
Increment (mm) 0.45 0.45
Time (sec) 9–10 3–5
Contrast
Volume (mL) 100 50–70
Rate (mL/sec) 3–4 4–5
Saline
Volume (mL) 30–50 30–40
Rate (mL/sec) 3–4 4–5

cost savings related to further reduction tion method involves the administration FIGURE 1. This 3-dimensional volume-
in contrast-media volume. of a small bolus of contrast to estimate rendered coronary CT angiogram shows the
the time to peak enhancement in a left anterior descending, diagonal, ramus,
obtuse marginal, and circumflex coronary
CTA protocols enabling region of interest. The results of the test arteries (Scan parameters: 128 × 0.625 mm
contrast-dose reductions injection are used to set injection para- collimation; 120 kV; 200 mAs; 0.27-sec rota-
CTA techniques are used to visualize meters for the main spiral scan. The tion time; 0.9-mm slice thickness; 0.45 mm
vascular anatomy and were initially bolus tracking method uses software to slice increment; prospectively gated axial
developed in the 1990s using single-slice automatically analyze contrast enhance- technique with 1 step). This image was
acquired using 70 mL of contrast media.
and early multislice CT scanners. How- ment at an anatomic location specified
ever, due to technical limitations, the in the particular examination protocol
coverage was limited to smaller vascular and to automatically begin the CT
regions.23 Current wide-coverage scan- acquisition at a preset time after the
ners, using state-of-the-art spiral acquisi- enhancement at that location reaches a
tion techniques, make it possible to predefined threshold.
consistently acquire high-quality scans The protocols and techniques for per-
of the entire vascular anatomy — from forming CTA scans vary by institution
the Circle of Willis (COW), through the and clinical indication. On a 64-channel
carotids and aorta, to the lower extremi- scanner, a typical head, thorax, and ab-
ties—within seconds. The faster rotation domen CTA examination requires the
speeds and larger detector coverage of administration of approximately 100 mL
these new scanners make it even more of contrast. The injection rate is 3 to
important to optimize contrast-injection 4 mL/sec, depending on the patient and
parameters to obtain maximum enhance- the protocol. Additionally, a 30 to
ment of the vascular structures of inter- 50-mL saline chaser bolus administered
est, while simultaneously minimizing the at 3 to 4 mL/sec may be used to obtain a
contrast load delivered to the patient. tighter bolus. Table 1 shows a typical
abdominal CTA protocol.24
Contrast-injection protocol The faster rotation time and wider
A wide variety of CT protocols, coverage per rotation of new CT scan-
including CTA exams, require contrast ners enable the contrast volume used FIGURE 2. This 3-dimensional volume-
injection. Head and neck, thoracic, during a typical CTA study to be rendered abdominal CT angiogram depicts a
abdominal, and peripheral runoff CTA reduced to 50 to 70 mL per patient, with patent aortoiliac graft, as well the renal and
studies are among the most common. an injection rate of 4 to 5 mL/sec and a visceral arteries (Scan parameters: 128 ×
The timing of the contrast bolus for 30 to 40 mL saline chaser injected at 0.625 mm collimation; 120 kV; 210 mAs;
0.75-sec rotation time; 0.9-mm slice thick-
CTA scans is typically determined using 4 to 5 mL/sec (Table 1). The CT angio- ness; 0.45-mm slice increment; 0.993 pitch).
either a test injection or automated grams depicted in Figures 1 and 2 were This image was acquired using 70 mL of
bolus-tracking software. The test injec- acquired using 70 mL of contrast. contrast media.

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LOW-CONTRAST-DOSE CTA

a summary of the institutional data and


Table 2. Institutional economic analysis the associated cost savings derived by
Sites Hospital 1 Hospital 2 Hospital 3
the use of a CT256 scanner.
National analysis was performed
No. of procedures (per year) 7200 10,000 4800 using values extrapolated from an
No. of CTA procedures 1080 1500 720 industry survey.1 The “average number
requiring contrast (per year) of procedures per system” and the
Average percentage of CTA 15% 15% 15% “number of procedures requiring con-
studies requiring contrast trast” were derived from this survey
Average contrast cost savings $12 $12 $12 data. The average per procedure con-
per procedure trast volume and per patient contrast
cost savings found through institutional
Average contrast cost $12,960 $18,000 $8640
analysis was then applied (Table 3).
savings (per year)
Both institutional and national analy-
CTA = computed tomography angiography ses indicate the potential to realize
cost savings through contrast volume
Table 3. National economic analysis: reductions if the CT256 is used instead
of CT64 for CTA. Such savings will
Estimate of cost savings per system
result in a reduction in cost-of-owner-
Average no. of CTA procedures (per year) 4500 ship and a positive impact on the depart-
Average percentage of CTA studies requiring contrast 10% ment’s annual operating budget. It is
Total no. of CTA procedures requiring contrast (per year) 450 estimated that 50% of CT providers use
bulk contrast at the national level, so
Average per-procedure contrast cost savings $12
contrast savings could have a signifi-
Average annual contrast cost savings $5400 cant positive impact on total cost-
CTA = computed tomography angiography of-care. Extrapolating the estimated
$5400 per system contrast cost savings
A comparison of the protocols pre- contrast used along with associated to just 200 CT256 systems would yield
sented in Table 1 reveals a contrast vol- actual contrast cost. >$1 million annual savings—a signifi-
ume reduction of approximately 30 mL Institutional data was collected from cant amount given the growing num-
per patient, per procedure. This contrast scan histories for CT64 systems from bers of imaging procedures and the
savings can lead to substantial eco- 3 radiology departments located in current national debate surrounding
nomic benefit and potential reduction 2 distinct geographic regions: Methodist healthcare costs and coverage.
in risk of CIN. Hospital (Indianapolis, IN), Metro- Further, the lower limits of contrast
Health Medical Center (Cleveland, OH), volume that enable diagnostic quality
Economic analysis of and the Oregon Health and Science Uni- scans to be produced are still under
contrast-volume reduction versity (Portland, OR). investigation. A limited number of pro-
In addition to the aforementioned Institutional analysis was based on cedures performed in the Midwest,
clinical benefits of reduced contrast the actual number of scans performed however, suggest that diagnostic image
utilization, the potential annualized over a prior 12-month period and the quality and vessel visualization can be
institutional and national cost of per- associated contrast volumes. Contrast achieved with greatly reduced contrast
forming contrast-enhanced CTA exam- cost estimates were based on a bulk volumes (S.D. Teague, MD, unpub-
inations using a CT scanner capable of delivery assumption of an average lished data, September 2008). While
achieving faster rotation times com- $0.40 per mL. On average, these institu- this evidence is still anecdotal, it is of
bined with wider coverage (CT256) tions administered 100 to 125 mL of interest to postulate the significant
can be compared to performing contrast per patient when scanned on potential benefit to a department’s
contrast-enhanced CTA exams with a the CT64. Similar patient examinations annual operating budget if this lower
64-channel system (CT64). In this performed on the CT256 used 70 mL of limit were to be achieved more regu-
comparison, institutional and national contrast, on average. For simplicity, this larly with diagnostic results.
benchmark data were used to estimate analysis assumes a more conservative
potential contrast-volume savings and per-patient average contrast volume Conclusion
associated cost benefits. At the institu- savings of 30 mL. Multiplying 30 mL Diagnostic image quality in CT
tional level, activity-based analyses by the $0.40 manifests a potential sav- angiography can be achieved using
were used to identify the volume of ings of $12 per patient. Table 2 presents lower effective contrast volumes with

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LOW-CONTRAST-DOSE CTA
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