CT Angiography Of PAD

dr. Alqi Yutha

• CT angiography is a useful modality in imaging the peripheral arterial
tree and has become an integral component in many cardiovascular
imaging practices
• Large portions of the arterial system can be easily imaged with
excellent spatial resolution, low radiation dose, and minimal risk to
the patient.
• Peripheral CT angiography has particular advantages as a non-invasive
means of depicting the systemic arterial tree and is able to
demonstrate a number of disease entities
Acquisition and Scanning Techniques
Special Considerations Regarding Peripheral CT Angiography

• In patients with severe atherosclerotic disease, the presence of

stenoses, occlusions, and aneurysms may delay optimal opacification
of the peripheral arteries
• the timing of peripheral CT angiography has separate considerations
that differ from scanning other, more proximal, body parts
• wider distribution of peripheral arterial structures in the transverse
plane. As a result, images may have lower in- plane spatial resolution
Contrast Administration
• rapid rates of contrast administration are critical in obtaining optimal
peripheral vascular opacification
• a more central, large bore, venous access line (usually consisting of an
18-gauge catheter in the antecubital fossa) is highly preferable to a
smaller or more peripheral venous access site
• Most studies for peripheral CT angiography report contrast rates of
3.5– 4.0 ccs per second as optimal
• Patients are usually given a formulation of intravenous contrast with
300–400 mg of iodine per mL, with 120–180 ccs of contrast given
depending on each patient’s body surface area
• When imaging the upper extremities, contrast injection should be made via
the extremity contralateral to the area of interest
• In patients with normal cardiac function, a rapid acquisition of images may
outpace the bolus of contrast
• In patients with depressed cardiac function or arterial pathology, the scanning
time should be prolonged to ensure scanning is not performed before arrival
of the contrast bolus
• the lower extremities are scanned twice, with a second acquisition beginning
just above the knees and timed immediately after the first acquisition
• biphasic injections result in more uniform enhancement over time, notably
with long scan and injection times (25–30 seconds)
Volume Rendering (VR)
• Volume rendering with a 3-dimensional perspective is useful for overall
topographic display, particularly in demonstrating collateral circulation.

• However, opacity settings may not provide an accurate rendering of vessel

contours and relative degree of stenosis, and vessel wall calcification is not as
clearly displayed as in a maximum intensity projection display.

• Volume rendering, without bone segmentation, is a powerful display

technique in the preintervention evaluation because it allows bony landmarks
and the accompanying soft tissue anatomy at sites of vascular disease to be
displayed and appreciated by interventional radiologists and vascular surgeons
Volume Rendering (VR)
Maximum intensity projection (MIP)
• Maximum intensity projection (MIP) provides a more accurate
rendition of vessel wall contour and vascular calcification than
volume rendering and is useful in the topographic display of the
outflow arterial circulation (femoropopliteal and tibioperoneal).

• However, in the abdomen and pelvis, a full-volume MIP suffers from

overlay of abdominal visceral arteries, particularly intestinal over the
aortoiliac inflow vessels. A subvolume slab MIP approach is best used
in the abdominal pelvic segment.
Maximum intensity projection (MIP)
Curved planar reformations (CPRs)
• Curved planar reformations (CPRs) using centerline tracking and edge
detection provide a view of selected vessel segments that is rotatable in real
time and allow the best projection angle to be selected for determining the
degree of asymmetric vessel stenosis.

• In addition, semi circumferential calcified plaque, which does not allow

determination of underlying vessel lumen in an MIP display, is projected at
the vessel edge in a CPR.

• CPRs are useful for the display of the vessel which can be displayed
separately from one to another vessels.
C
P
R
Validation of Peripheral CT Angiography
• Rapid Advancement in CT Technology  large multicenter studies and
meta-analyses likely underestimate the accuracy of CT angiography as
a tool
CT
DSA fourfold lower radiation dose and a much lower risk of
complications
DUS does not significantly depend on variability of technical skills

MRA limitations in patients with stents, surgical clips, or other

devices, and is problematic in patients with non-MR
conditional cardiac devices
Role of Peripheral CT Angiography for the Vascular
Physician
Variants
Variants
Variants
Stenosis sizing
• Stenosis sizing is usually determined by visual observation or ‘‘eyeballing’’ rather
than a computer-based technique.

• The combination of MIP, CPR, and axial plane imaging allows the experienced
observer to categorize stenoses in the
mild (0%–50%)
moderate (50%–70%)
severe (>70%)
Stenoses less than 50% are not considered as hemodynamically significant.
Moderate and severe grades of stenoses are hemodynamically significant and
compensated by development of collateral circulation.
Stenosis sizing
The combination of projectional display using a rotatable CPR with correlative axial imaging
of defined levels of stenosis achieves the best results.

The MIP technique, which is essentially a 2-dimensional projectional display, is unable to

resolve the degree of stenosis at sites of circumferential calcified plaque. Only in patients with
almost complete circumferential heavily calcified plaque is the curved planar reformation
unable to demonstrate the residual contrast-enhanced lumen.

Automated methods of stenosis sizing allow diameter and area reduction techniques to be
used. Area reduction is intrinsically superior to diameter reduction because it provides a
better estimate of flow reduction.
For asymmetric stenoses, accurate determination of diameter reduction requires the right
projection to be determined when the images are being examined at the diagnostic console.
Stenosis or occlusion
Vessel stenosis or occlusion can be elicited during dynamic imaging by asking the patient to
repeatedly plantarflex and dorsiflex during the imaging study. In some instances, vessel
narrowing can be observed during static imaging

In the setting of atherosclerotic calcification, the original reconstructed data must be

analyzed to avoid overestimation of the degree of stenosis that may occur owing to
“blooming” of the calcification on the MIPs.

For similar reasons, 3-D VR images, although useful for overall evaluation of the vascular tree
and localization/visualization of possible abnormalities, should not be used exclusively to
quantify the degree of stenosis. However, both 3-D VR images and MIPs can be useful for
measuring craniocaudal extent of arterial occlusions, evaluating collateral vessels, and
characterizing traumatic vascular injuries.
• the use of narrow viewing window settings in the presence of arterial wall
calcifications or stents.

• high-attenuation objects (eg, calcified plaque, stents) appear larger than they
really are (“blooming”), which may lead to an overestimation of a vascular
stenosis or suggest a spurious occlusion
 SUMMARY
Clinical context
• Goal is to map lesions to clinical symptops

Postprocessing
• Curved planar reformats
• Maximum intensity projection
• Volume rendering

Interpretation & Reporting

• Don't read study without knowing symptomps
• Answer clinical question rather listing lesions
Thank you