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
computed tomography (MDCT)
throughout the past decade has
established its position as the workhorse
of radiology. In addition to facilitating
faster and improved diagnoses in the rou-
tine examinations—such as thoracic, ab-
dominal, pelvic, brain, neck, and spine—
that make up >85% of annual CT
exams,1 this evolution has sparked a
surge in vascular imaging procedures,
such as CT angiography (CTA).
From 2004 to 2007 alone, the number
of annual CTA procedures in the United
States more than doubled to 4.7 million.1
The concurrent increase in the number
of sites regularly performing CTA pro-
cedures, from 44% to 67% in the same
time period,1 further supports the adop-
tion of MDCT as the noninvasive mo-
dality of choice for imaging the anatomy
Dr. Teague is an Assistant Professor of
Radiology, Department of Radiology,
Indiana University School of Medicine,
Indianapolis, IN. Dr. Rosenblum is Vice
Chair, Department of Radiology, and
Director, Interventional Radiology,
MetroHealth Medical Center, and Assis-
tant Professor of Radiology, Case West-
ern Reserve University, Cleveland, OH.
Dr. Olszewski is a Research Scientist,
Ms. Dharaiya is a Research Scientist,
and Mr. Popilock is a Product Manager,
Computed Tomography Clinical Science,
Philips Healthcare, Cleveland, OH.
40A ■ APPLIED RADIOLOGY ©
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in most vascular territories.2,3 Despite
the growing acceptance of this technol-
ogy, the rapid rate of procedure growth
has led to renewed concerns regarding
both the radiation dose4-7 and the
amount of intravenous contrast deliv-
ered6,7 to patients undergoing CTA.
Minimizing patient radiation dose is
of paramount concern when using
MDCT. As MDCT procedures have
grown, studies have shown that CT is
an increasing source of radiation expo-
sure,4 and attempts have been made to
estimate the increase in cancer risk due
to CTA procedures.5 Imaging equip-
ment vendors have made progress in
the area of radiation dose management
with the introduction of novel technolo-
gies, such as prospective electrocardio-
graphic (ECG)-gating with advanced
algorithms to handle cardiac arrhyth-
mias, improved beam filtration technol-
ogy, and dose-reducing collimators.
Concurrent efforts are underway across
the industry and in academia to provide
recommendations for the responsible
imaging of pediatric patients.6,7
At the same time, the amount of con-
trast media delivered to a patient is also
of utmost concern due to the risk of com-
plications, particularly contrast-induced
nephropathy (CIN). Contrast-induced
nephropathy is defined as acute renal fail-
ure occurring within 48 hours of expo-
sure to intravascular radiographic con-
trast material that is not attributable to
other causes, and it is the third most com-
mon cause of hospital-acquired acute
renal failure.8,9 Prevention of CIN has
been the subject of many studies10; but the
development of new contrast formula-
tion,11,12 injection technique,13 and pre-
treatment paradigm,14 strategies to
prevent CIN are implemented nonuni-
formly15 and have shown varied results.16
It is well-known that vessel visual-
ization in CTA benefits from higher
contrast volumes, concentrations, and
injection rates;17,18 however, the risk of
CIN increases with increased contrast
volume.9,16 Studies using earlier genera-
tion MDCT scanners evaluated the pos-
sibility of reducing the contrast volume
necessary for various types of CTA
examinations,19-22 but it may be possible
to consistently decrease contrast vol-
umes across a wider patient population.
Efforts to further reduce contrast vol-
ume per patient study may reduce the
risk of CIN and provide institutions
with an overall economic benefit.
This article details the clinical and
economic benefits of reduced contrast
doses made possible by new CT scanner
technology that is enhanced for speed,
power, and coverage. This combination
of technologic advances may enable
high-quality imaging of all pa-tients
with a consistent reduction in contrast
volume of ≥35%, while maintaining
image quality. Finally, the authors pro-
vide an economic analysis of potential
March 2009

Table 1. CT angiography scan and contrast injection
protocols for 64- and 256-slice CT scanners
Protocol 64-slice
kV 120
Field of view (mm) 300–400
Slice thickness (mm) 0.9
Increment (mm) 0.45
Time (sec) 9–10
Contrast
Volume (mL) 100
Rate (mL/sec) 3–4
Saline
Volume (mL) 30–50
Rate (mL/sec) 3–4
cost savings related to further reduction
in contrast-media volume.
CTA protocols enabling
contrast-dose reductions
CTA techniques are used to visualize
vascular anatomy and were initially
developed in the 1990s using single-slice
and early multislice CT scanners. How-
ever, due to technical limitations, the
coverage was limited to smaller vascular
regions.23 Current wide-coverage scan-
ners, using state-of-the-art spiral acquisi-
tion techniques, make it possible to
consistently acquire high-quality scans
of the entire vascular anatomy — from
the Circle of Willis (COW), through the
carotids and aorta, to the lower extremi-
ties—within seconds. The faster rotation
speeds and larger detector coverage of
these new scanners make it even more
important to optimize contrast-injection
parameters to obtain maximum enhance-
ment of the vascular structures of inter-
est, while simultaneously minimizing the
contrast load delivered to the patient.
Contrast-injection protocol
A wide variety of CT protocols,
including CTA exams, require contrast
injection. Head and neck, thoracic,
abdominal, and peripheral runoff CTA
studies are among the most common.
The timing of the contrast bolus for
CTA scans is typically determined using
either a test injection or automated
bolus-tracking software. The test injec-
March 2009
LOW-CONTRAST-DOSE CTA
256-slice
120
300–400
0.9
0.45
3–5
50–70
4–5
30–40
4–5
tion method involves the administration FIGURE 1. This 3-dimensional 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
region of interest. The results of the test arteries (Scan parameters: 128 × 0.625 mm
injection are used to set injection para- collimation; 120 kV; 200 mAs; 0.27-sec rota-
meters for the main spiral scan. The tion time; 0.9-mm slice thickness; 0.45 mm
bolus tracking method uses software to slice increment; prospectively gated axial
automatically analyze contrast enhance- technique with 1 step). This image was
acquired using 70 mL of contrast media.
ment at an anatomic location specified
in the particular examination protocol
and to automatically begin the CT
acquisition at a preset time after the
enhancement at that location reaches a
predefined threshold.
The protocols and techniques for per-
forming CTA scans vary by institution
and clinical indication. On a 64-channel
scanner, a typical head, thorax, and ab-
domen CTA examination requires the
administration of approximately 100 mL
of contrast. The injection rate is 3 to
4 mL/sec, depending on the patient and
the protocol. Additionally, a 30 to
50-mL saline chaser bolus administered
at 3 to 4 mL/sec may be used to obtain a
tighter bolus. Table 1 shows a typical
abdominal CTA protocol.24
The faster rotation time and wider
coverage per rotation of new CT scan-
ners enable the contrast volume used FIGURE 2. This 3-dimensional volume-
during a typical CTA study to be rendered abdominal CT angiogram depicts a
reduced to 50 to 70 mL per patient, with patent aortoiliac graft, as well the renal and
an injection rate of 4 to 5 mL/sec and a visceral arteries (Scan parameters: 128 ×
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-
4 to 5 mL/sec (Table 1). The CT angio- ness; 0.45-mm slice increment; 0.993 pitch).
grams depicted in Figures 1 and 2 were This image was acquired using 70 mL of
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
Sites Hospital 1
No. of procedures (per year) 7200
No. of CTA procedures 1080
requiring contrast (per year)
Average percentage of CTA 15%
studies requiring contrast
Average contrast cost savings $12
per procedure
Average contrast cost $12,960
savings (per year)
CTA = computed tomography angiography
Table 3. National economic analysis:
Estimate of cost savings per system
Average no. of CTA procedures (per year)
Average percentage of CTA studies requiring contrast
Total no. of CTA procedures requiring contrast (per year)
Average per-procedure contrast cost savings
Average annual contrast cost savings
CTA = computed tomography angiography
A comparison of the protocols pre-
sented in Table 1 reveals a contrast vol-
ume reduction of approximately 30 mL
per patient, per procedure. This contrast
savings can lead to substantial eco-
nomic benefit and potential reduction
in risk of CIN.
Economic analysis of
contrast-volume reduction
In addition to the aforementioned
clinical benefits of reduced contrast
utilization, the potential annualized
institutional and national cost of per-
forming contrast-enhanced CTA exam-
inations using a CT scanner capable of
achieving faster rotation times com-
bined with wider coverage (CT256)
can be compared to performing
contrast-enhanced CTA exams with a
64-channel system (CT64). In this
comparison, institutional and national
benchmark data were used to estimate
potential contrast-volume savings and
associated cost benefits. At the institu-
tional level, activity-based analyses
were used to identify the volume of
Hospital 2 Hospital 3
10,000 4800
1500 720
15% 15%
$12 $12
$18,000 $8640
4500
10%
450
$12
$5400
contrast used along with associated
actual contrast cost.
Institutional data was collected from
scan histories for CT64 systems from
3 radiology departments located in
2 distinct geographic regions: Methodist
Hospital (Indianapolis, IN), Metro-
Health Medical Center (Cleveland, OH),
and the Oregon Health and Science Uni-
versity (Portland, OR).
Institutional analysis was based on
the actual number of scans performed
over a prior 12-month period and the
associated contrast volumes. Contrast
cost estimates were based on a bulk
delivery assumption of an average
$0.40 per mL. On average, these institu-
tions administered 100 to 125 mL of
contrast per patient when scanned on
the CT64. Similar patient examinations
performed on the CT256 used 70 mL of
contrast, on average. For simplicity, this
analysis assumes a more conservative
per-patient average contrast volume
savings of 30 mL. Multiplying 30 mL
by the $0.40 manifests a potential sav-
ings of $12 per patient. Table 2 presents
the associated cost savings derived by
the use of a CT256 scanner.
National analysis was performed
using values extrapolated from an
industry survey.1 The “average number
of procedures per system” and the
“number of procedures requiring con-
trast” were derived from this survey
data. The average per procedure con-
trast volume and per patient contrast
cost savings found through institutional
analysis was then applied (Table 3).
Both institutional and national analy-
ses indicate the potential to realize
cost savings through contrast volume
reductions if the CT256 is used instead
of CT64 for CTA. Such savings will
result in a reduction in cost-of-owner-
ship and a positive impact on the depart-
ment’s annual operating budget. It is
estimated that 50% of CT providers use
bulk contrast at the national level, so
contrast savings could have a signifi-
cant positive impact on total cost-
of-care. Extrapolating the estimated
$5400 per system contrast cost savings
to just 200 CT256 systems would yield
>$1 million annual savings—a signifi-
cant amount given the growing num-
bers of imaging procedures and the
current national debate surrounding
healthcare costs and coverage.
Further, the lower limits of contrast
volume that enable diagnostic quality
scans to be produced are still under
investigation. A limited number of pro-
cedures performed in the Midwest,
however, suggest that diagnostic image
quality and vessel visualization can be
achieved with greatly reduced contrast
volumes (S.D. Teague, MD, unpub-
lished data, September 2008). While
this evidence is still anecdotal, it is of
interest to postulate the significant
potential benefit to a department’s
annual operating budget if this lower
limit were to be achieved more regu-
larly with diagnostic results.
Conclusion
Diagnostic image quality in CT
angiography can be achieved using
lower effective contrast volumes with

40C ■ APPLIED RADIOLOGY ©

www.appliedradiology.com March 2009

the latest CT technology that optimizes
speed, power, coverage, and dose man-
agement. Operating cost benefits are
realized through a reduction in per-
patient contrast volumes, while patients
benefit from a reduced risk of contrast-
induced nephropathy and lower lifetime
medical radiation exposure.
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