Potential clinical and economic benefits of low-contrast-dose CT angiography.

The 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 routine examinations--such as thoracic, abdominal, 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 procedures, from 44% to 67% in the same time period, (1) further supports the adoption of MDCT as the noninvasive modality of choice for imaging the anatomy in most vascular territories. (2,3) Despite the growing acceptance of this technology, the rapid rate of procedure growth has led to renewed concerns regarding both the radiation dose (4-7) and the amount of intravenous contrast delivered (6,7) 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 exposure, (4) and attempts have been made to estimate the increase in cancer risk due to CTA procedures. (5) Imaging equipment vendors have made progress in the area of radiation dose management with the introduction of novel technologies, such as prospective electrocardiographic (ECG)-gating with advanced algorithms to handle cardiac arrhythmias, improved beam filtration technology, 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 contrast media delivered to a patient is also of utmost concern due to the risk of complications, particularly contrast-induced nephropathy (CIN). Contrast-induced nephropathy is defined as acute renal failure occurring within 48 hours of exposure to intravascular radiographic contrast material that is not attributable to other causes, and it is the third most common cause of hospital-acquired acute renal failure. (8,9) Prevention of CIN has been the subject of many studies (10); but the development of new contrast formulation, (11,12) injection technique, (13) and pretreatment para digm, (14) strategies to prevent CIN are implemented nonuniformly (15) and have shown varied results. (16)

It is well-known that vessel visualization 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 generation MDCT scanners evaluated the possibility of reducing the contrast volume necessary for various types of CTA examinations, (19-22) but it may be possible to consistently decrease contrast volumes across a wider patient population. Efforts to further reduce contrast volume 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 patients with a consistent reduction in contrast volume of [greater than or equal to] 35%, while maintaining image quality. Finally, the authors provide an economic analysis of potential 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. However, due to technical limitations, the coverage was limited to smaller vascular regions. (23) Current wide-coverage scanners, using state-of-the-art spiral acquisition 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 extremities--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 enhancement of the vascular structures of interest, 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 injection method involves the administration of a small bolus of contrast to estimate the time to peak enhancement in a region of interest. The results of the test injection are used to set injection parameters for the main spiral scan. The bolus tracking method uses software to automatically analyze contrast enhancement 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 performing CTA scans vary by institution and clinical indication. On a 64-channel scanner, a typical head, thorax, and abdomen 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 scanners enable the contrast volume used during a typical CTA study to be reduced to 50 to 70 mL per patient, with an injection rate of 4 to 5 mL/sec and a 30 to 40 mL saline chaser injected at 4 to 5 mL/sec (Table 1). The CT angiograms depicted in Figures 1 and 2 were acquired using 70 mL of contrast.

A comparison of the protocols presented in Table 1 reveals a contrast volume reduction of approximately 30 mL per patient, per procedure. This contrast savings can lead to substantial economic benefit and potential reduction in risk of CIN.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

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 performing contrast-enhanced CTA examinations using a CT scanner capable of achieving faster rotation times combined 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 institutional level, activity-based analyses were used to identify the volume of 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), MetroHealth Medical Center (Cleveland, OH), and the Oregon Health and Science University (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 institutions 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 savings of $12 per patient. Table 2 presents a summary of the institutional data and 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 contrast" were derived from this survey data. The average per procedure contrast volume and per patient contrast cost savings found through institutional analysis was then applied (Table 3).

Both institutional and national analyses 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-ownership and a positive impact on the department'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 significant positive impact on total costofcare. Extrapolating the estimated $5400 per system contrast cost savings to just 200 CT256 systems would yield >$1 million annual savings--a significant amount given the growing numbers 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 procedures 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, unpublished 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 regularly with diagnostic results.

Conclusion

Diagnostic image quality in CT angiography can be achieved using lower effective contrast volumes with the latest CT technology that optimizes speed, power, coverage, and dose management. Operating cost benefits are realized through a reduction in perpatient contrast volumes, while patients benefit from a reduced risk of contrastinduced nephropathy and lower lifetime medical radiation exposure.

REFERENCES

(1.) IMV Medical Information Division. 2007 CT Market Summary Report. Technical Report. 2007.

(2.) Napoli, A, Fleischmann, D, Chan, FP, et al. Computed tomography angiography: State-of-theart imaging using multidetector-row technology. J Comput Assist Tomogr. 2004;28(Suppl 1):S32-S45.

(3.) Fleischmann D. Present and future trends in multiple detector-row CT applications: CT angiography. Eur Radiol. 2002;12(Suppl 2):S11-S15.

(4.) Brenner, DJ, Hall, EJ. Computed tomography -An increasing source of radiation exposure. N Engl J Med. 2007;357:2277-2284.

(5.) Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007;298:317-323.

(6.) Goske MJ, Applegate KE, Boylan J, et al. The Image Gently campaign: Increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol. 2008;38:265-269.

(7.) Goske MJ, Applegate KE, Boylan J, et al. The Image Gently campaign: Working together to change practice. AJR Am J Roentgenol. 2008;190: 273-274.

(8.) Tublin ME, Murphy ME, Tessler FN. Current concepts in contrast media-induced nephropathy. AJR Am J Roentgenol. 1998;171:933-939.

(9.) Walsh SR, Tang T, Gaunt ME, Boyle JR. Contrast-induced nephropathy. J Endovasc Ther. 2007;14:92-100.

(10.) van Praet JT, Vriese ASD. Prevention of contrastinduced nephropathy: A critical review. Curr Opin Nephrol Hypertens. 2007;16:336-347.

(11.) From AM, Bartholmai BJ, Williams AW, McDonald FS. Iodixanol compared to iohexol for contrast procedures: A case-matched retrospective cohort study. Acta Radiol. 2008;49:409-414.

(12.) Kuhn MJ, Chen N, Sahani DV, et al. The PREDICT study: A randomized double-blind comparison of contrast-induced nephropathy after low- or iso osmolar contrast agent exposure. AJR Am J Roentgenol. 2008;191:151-157.

(13.) Dorio PJ, Lee FT, Henseler KP, et al. Using a saline chaser to decrease contrast media in abdominal CT. AJR Am J Roentgenol. 2003;180:929-934.

(14.) Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: A randomized controlled trial. JAMA. 2004;291:2328-2334.

(15.) Weisbord SD, Mor MK, Resnick AL, et al. Prevention, incidence, and outcomes of contrastinduced acute kidney injury. Arch Intern Med. 2008; 168:1325-1332.

(16.) Meschi M, Detrenis S, Musini S, et al. Facts and fallacies concerning the prevention of contrast medium-induced nephropathy. Crit Care Med. 2006;34:2060-2068.

(17.) Furuta A, Ito K, Fujita T, et al. Hepatic enhancement in multiphasic contrast-enhanced MDCT: Comparison of high- and low-iodine-concentration contrast medium in same patients with chronic liver disease. AJR Am J Roentgenol. 2004;183: 157-162.

(18.) Diehm N, Kickuth R, Gahl B, et al. Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements. J Vasc Surg. 2007;45:263-268.

(19.) Schoellnast H, Tillich M, Deutschmann HA, et al. Abdominal multidetector row computed tomography: Reduction of cost and contrast material dose using saline flush. J Comput Assist Tomogr. 2003;27: 847-853.

(20.) de Monye C, Cademartiri F, de Weert TT, et al. Sixteen-detector row CT angiography of carotid arteries: Comparison of different volumes of contrast material with and without a bolus chaser. Radiology. 2005;237:555-562.

(21.) Kubo S, Tadamura E, Yamamuro M, et al. Thoracoabdominalaortoiliac MDCT angiography using reduced dose of contrast material. AJR Am J Roentgenol. 2006;187:548-554.

(22.) Diehm N, Pena C, Benenati JF, et al. Adequacy of an early arterial phase low-volume contrast protocol in 64-detector computed tomography angiography for aortoiliac aneurysms. J Vasc Surg. 2008; 47:492-498.

(23.) Hallett R, Fleischmann D. Tools of trade for CTA: MDCT scanners and contrast medium injection protocols. Tech Vasc Interv Radiol. 2006;9:134-142.

(24.) Chen JJ, White CS. CT angiography for coronary artery bypass graft surgery. Appl Radiol. 2008; 37(7):10-18.

Shawn D. Teague, MD, David I. Rosenblum, DO, Mark E. Olszewski, PhD, Ekta Dharaiya, MS, and Robert Popilock, BS, RTR 

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 Assistant Professor of Radiology, Case Western 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.

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

Table 2. Institutional economic analysis

Sites                             Hospital 1   Hospital 2   Hospital 3

No. of procedures (per year)         7200        10,000        4800
No. of CTA procedures                1080         1500          720
  requiring contrast (per year)
Average percentage of CTA             15%          15%          15%
  studies requiring contrast
Average contrast cost savings        $12          $12          $12
  per procedure
Average contrast cost              $12,960      $18,000       $8640
  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)                      4500
Average percentage of CTA studies requiring contrast          10%
Total no. of CTA procedures requiring contrast (per year)     450
Average per-procedure contrast cost savings                   $12
Average annual contrast cost savings                         $5400

CTA = computed tomography angiography