03 May 2023: Clinical Research
A Feasibility Study to Evaluate Replacing Conventional Computed Tomography at 120 KVP with Low Radiation Dose and Low Iodine Intake Based on Body Mass Index-Adapted Abdominal Computed Tomography Angiography in 291 PatientsXin Fang1E, Yijun Liu1A*, Zijing Zhang1B, Wei Wei1B, Xu Wang1F, Beibei Li 1F, Xiaoyu Tong 1C
Med Sci Monit 2023; 29:e939228
BACKGROUND: This feasibility study aimed to evaluate replacing conventional computed tomography at 120 kVp with low radiation and low iodine dose based on body mass index (BMI)-adapted abdominal computed tomography angiography in 291 patients.
MATERIAL AND METHODS: A total of 291 abdominal CTA patients were divided into 3 individualized kVp groups according to their BMI: A1 with 70 kVp (n=57), A2 with 80 kVp (n=49), and A3 with 100 kVp (n=48); and 3 conventional 120 kVp groups: B1 (n=40), B2 (n=53), and B3 (n=44) BMI-matched with group A. The contrast media was 300 mgI/kg for group A and 500 mgI/kg for group B. The CT values and SD of the abdominal aorta and the erector spinae were measured, and the contrast-to-noise ratio (CNR) and figure-of-merit (FOM) were calculated. Imaging quality, radiation, and contrast media dosage were evaluated.
RESULTS: The CT and CNR of abdominal aorta in groups A1 and A2 were higher than those in groups B1 and B2 (P<0.05), but there was no significant difference between groups A3 and B3 (P>0.05). FOM of the abdominal aorta in group A was higher than that in group B (P<0.05). Compared with groups B1, B2, and B3, the radiation doses of A1, A2, and A3 groups decreased by 70.61%, 56.72%, and 31.87%, and contrast intake decreased by 39.94%, 38.74%, and 35.09%, respectively (P<0.05).
CONCLUSIONS: BMI-based individualized kVp abdominal CTA imaging significantly reduced overall radiation dose and contrast media intake while providing excellent image quality.
Keywords: Aorta, Abdominal, Body Mass Index, Radiation Dosage
CTA has the advantages of simplicity, noninvasiveness, and inexpensiveness compared with DSA, which is widely used in clinical practice . It can clearly reflect the anatomical characteristics of the vascular direction, the relationship between blood vessels and tumors, and shows the variation of blood vessels [2,3]. At present, the 120 kVp tube voltage is typically used in most conventional abdominal CTA scans, which results in higher radiation dosages for patients. Contrast media is one of the important factors affecting organizational enhancement [4,5]. To ensure the image quality and contrast of arterial display, contrast media with high concentration, high volume, and high injection rate is traditionally used . However, excessive use of iodine contrast media may also cause adverse reactions, such as postcontrast acute kidney injury [6,7]. The attenuation of iodine contrast media increases gradually with the loss of the photon energy. Low-energy X-ray tube voltage to the iodine K-edge [8–10] provides technical assurance for optimizing blood vessel display without increasing the concentration of contrast media [11,12]. However, the penetration capacity of low tube voltage is limited, and the patient’s body size needs to be considered. Therefore, this feasibility study aimed to evaluate replacing conventional computed tomography at 120 kVp with a low radiation and low iodine dose body mass index (BMI)-adapted abdominal computed tomography angiography in 291 patients.
Material and Methods
PATIENT POPULATION AND STUDY DESIGN:
This prospective, single-institution study was approved by the Institutional Review Board, and written informed consent was provided by each patient. From December 2015 to June 2019, 317 consecutive patients received tri-phase abdominal CTA. Patients with iodine contrast media allergy, known renal dysfunction, heart failure, or liver dysfunction were excluded. Aortic dissection was another exclusion criterion, as it causes inhomogeneous enhancement of the aorta and separates the aortic lumen into true and false lumens. Finally, 26 patients were excluded and a total of 291 patients (183 males, 108 females; age range 21–85 years; mean age 63 years) were enrolled in the study and randomly divided into an individualized kVp group (group A) and a conventional 120 kVp group (group B). Patients were further divided into subgroups according to BMI: groups A1 and B1 (BMI ≤21 kg/m2), A2 and B2 (21 kg/m2 <BMI ≤24 kg/m2), and A3 and B3 (24 kg/m2 <BMI ≤27 kg/m2) (Table 1).
CT EXAMINATION METHODS:
All patients were scanned with a 256-row CT scanner (Revolution CT, GE Healthcare, Waukesha WI, USA). The scan parameters were as follows: Group A1, A2, and A3 were scanned with 70 kVp, 80 kVp, and 100 kVp, respectively; Group B1, B2, and B3 were scanned with conventional scan protocol (120 kVp). The common scan parameters included automatic tube current modulation (50–500 mA), rotation speed 0.5 s/r, pitch 0.992, matrix 512×512, thickness and layer space 5mm, with 50% pre-adaptive statistical iterative reconstruction-V (pre-ASIR-V 50%) for reducing dose requirement. The nonionic contrast media ioversol (320 mgI/ml) was injected using a dual-tube power injector (Ulrich, German) from the cubital vein. The contrast media intake in the A1–A3 groups was 300 mgI/kg body weight at a speed of 4.0 ml/s, while that in the B1–B3 groups was 500 mgI/kg at a speed of 4.5 ml/s, followed by a saline flush of 40 ml. To obtain an optimal intraluminal contrast enhancement, Smart Prep technique was used with ROI placed on the abdominal aorta at the level of diaphragmatic dome, and the scan-triggering threshold was 180 HU. The arterial-phase scan started 5.9 s after triggering. The scan range was from superior border of diaphragm to inferior border of pubic symphysis. Arterial-phase images in all groups were reconstructed with 50% ASIR-V, standard kernel, thickness and interval of 1.25 mm. Maximum intensity projection (MIP) and volume rendering (VR) were constructed on the AW4.7 workstation (Advantage Workstation, GE Healthcare).
OBJECTIVE IMAGE EVALUATION:
The ROIs were selected at 3 different levels (celiac trunk, renal artery, and common iliac artery) covering 70–80% of the area of the blood vessel, and the right spine erector spinae was selected as the background, with an average area of 50 mm2. Each ROI was measured 3 times, and the average value was computed. The contrast-to-noise ratio (CNR) was calculated as CNR = (CT abdominal aorta - CT erector spinae)/SD erector spinae. Figure-of-Merit (FOM) is a comprehensive index for evaluation of image quality and radiation dose, which can compare the comprehensive cost-performance among different CT scanning schemes. The larger the FOM value, the higher the cost-performance ratio of image quality and radiation dose. FOM was calculated as FOM=CNR2/CTDIvol.
SUBJECTIVE IMAGE EVALUATION: The subjective image quality of all examinations was evaluated and scored by 2 radiologists with 5 and 6 years of CT diagnostic experience, respectively. The readers were blinded to the scanning parameters without knowing basic information about patients. The comprehensive score of single subjective in vessel contrast, small vessel, image noise, and diagnostic confidence was on a 5-point scale. The scoring criteria are listed in Table 2. Three or more points were considered to be good clinical diagnostic image quality.
RADIATION DOSE AND CONTRAST MEDIA INTAKE:
Radiation dose was recorded on the device as CT dose index volume (CTDIvol) in the unit of mGy and dose-length product (DLP) in the unit of mGy cm, and effective dose (ED) was calculated using the formula ED =DLP×k, in which k represents the radiation dose conversion factor with a value of 0.015 mSv/(mGy·cm) for the abdomen. Contrast media dosage was recorded.
All measurements were analyzed with SPSS 24.0 (SPSS, Inc. Chicago, IL) software. Normality of data was tested using the Shapiro-Wilk test. Continuous data were expressed as mean±standard deviation. The unpaired
The characteristics of the 2 groups of patients are shown in Table 1. The patient characteristics, including sex, age, height, weight, BMI, and scanning range, were not significantly different between groups A1 and B1, A2 and B2, and A3 and B3 (all P>0.05).
OBJECTIVE IMAGE EVALUATION:
The comparison of objective parameters in abdominal CTA between any 2 BMI-matching groups is listed in Tables 3 and 4. The CT value and CNR of abdominal aorta and SD of erector spinae (noise) in groups A1 and A2 were higher than those in groups B1 and B2, and the difference was statistically significant (all P<0.001), while CT value and CNR of abdominal aorta and SD of erector spinae in group A3 and B3 were not significantly different (P>0.05). FOM of abdominal aorta of groups A1, A2, and A3 were higher than those of groups B1, B2, and B3, and the differences were statistically significant (all P<0.001).
SUBJECTIVE IMAGE EVALUATION:
The subjective scores of abdominal CTA are listed in Table 5. The 2 observers had good consistency in the image quality scores of group A and group B (Kappa >0.75, P<0.05), and the subjective scores of all the reconstructed images were greater than 3 points. Abdominal CTA is high-contrast imaging. Although decreasing tube voltage increases image noise correspondingly, it does not affect the subjective quality score of the image. There was no significant difference in vessel contrast, small vessel, and diagnostic confidence of image between group A1 and group B1, group A2 and group B2, and group A3 and group B3 (all P≥0.05) (Figures 1–3).
RADIATION DOSE AND CONTRAST MEDIA INTAKE:
The radiation dose and contrast media intake are listed in Table 6. There were significant differences in CTDIvol, DLP, ED, and contrast agent between A and B groups (all P<0.001). Compared with groups B1, B2, and B3, CTDIvol of groups A1, A2, and A3 decreased by 70.75%, 56.63%, and 32.78%, respectively. DLP decreased by 70.61%, 56.72%, and 31.87%, respectively, and ED decreased by 70.61%, 56.72%, and 31.87%, respectively (all P<0.001). Iodine contrast dose decreased by 39.94%, 38.74%, and 35.09%, respectively (all P<0.001).
Our study found that BMI-based individualized kVp abdominal CTA imaging significantly reduces overall radiation dose and contrast media intake, which can replace conventional abdominal CTA at 120 kVp and provided excellent image quality in 291 patients. With the rapid development of CT imaging technology, CT imaging parameters (eg, tube voltage, tube current, layer thickness, reconstruction algorithm) are continuously updated to improve image quality and scanning efficiency [13,14]. Abdominal CTA is superior for showing the structure of the tumor’s feeding arteries and abdominal vessels. However, large doses of radiation and contrast media are often required to obtain high image quality . Therefore, it is of vital importance to develop a dual low-dose standardized abdominal CTA scanning program [16–18]. For CTA examination, CNR is the most critical evaluation index , which is mainly positively correlated with the degree of vascular enhancement and negatively correlated with image noise intensity. As for the improvement of the vascular enhancement degree, this study applied 70–100 kVp low-voltage scanning technology to individualize the blood vessels according to the patient’s BMI, which greatly improved the degree of vascular enhancement compared with conventional 120 kVp scanning. Although the amount of contrast intake decreased, the CT value can be increased significantly by the K front of iodide ions at low voltage. Sauter  showed that 40 keV virtual monochromatic image had better diagnostic confidence and subjective contrast compared with a conventional CT at 100 kVp. The CT value in study groups A1 and A2 was 26.84% and 24.60% higher than that of conventional groups B1 and B2, respectively, while the CT value in group A3 remained at the same level as in group B3. Tube voltage in CT scanners represents the penetrating ability of X-rays, which is an important factor to determine the photon energy. Reduction of kVp can significantly improve image contrast. Meanwhile, as the radiation dose varies by the square of the tube voltage , it can also greatly reduce the radiation dose to patients. Fink et al  demonstrated that BMI-adapted, low-radiation, and low-iodine dose CTA of the thoracoabdominal aorta delivers diagnostic image quality in non-obese and obese patients without symptoms of high-grade heart failure.
Therefore, we considered whether individualized kVp could be used to minimize the radiation dose while maintaining image quality. Based on a GE Revolution CT scanner, we used individualized kVp abdominal CTA with low-iodine contrast media. Our study included patients with BMI ≤27 kg/m2, divided into 3 groups according to their BMI. Our design was consistent with the opinion proposed by multiple studies that BMI is an essential basis for selecting tube voltage level . Our results showed that radiation doses in the individualized kVp groups were reduced by 70.61%, 56.72% and 31.87%, respectively, compared with the control groups, which is consistent with the results of Nagayama , and Ren .Choi et al  also showed that 80 kVp CT reduced the radiation dose by 45.2% in oncology patients while showing comparable or superior image quality to that of 80/Sn150 kVp CT for abdominal tumor evaluation.
The harm of contrast-induced nephropathy (CIN) has also received widespread attention. To reduce the risk of CIN, contrast media intake should be minimized. Due to the X-ray absorption characteristic of the iodine contrast media, a lower tube voltage closing to the K-edge of iodine (33.2 keV) can significantly increase the CT value of iodine contrast media in the blood vessel and therefore improve the differentiation between abdominal aorta and surrounding tissues. We employed the iodine intake at 300 mgI/kg, which was 40% less than the standard contrast dose. Yu  proved that the iodine attenuation can be equivalent or even higher at reduced contrast dose at low kVp scanning to provide a similar contrast-noise ratio (CNR) compared to the 120 kVp conventional scanning. The higher iodine attenuation with low-kVp can partially offset higher image noise, providing potential to reduce radiation doses. It is precise because of the high-contrast imaging of blood vessels and surrounding soft tissues in abdominal CTA that patients from the low-dose group in this study had high subjective scores, which shows no significant difference compared with the conventional group. The study used 300 mgI/kg of contrast media and the iodine contrast media intake was lower than that in the previous study of abdominal CTA using low iodine contrast media. Compared with conventional 500 mgI/kg contrast media intake, groups B1, B2, and B3 decreased by 39.94%, 38.74%, and 35.09%, respectively. Contrast media intake was lower than that in the Ren  study. The CNR of the abdominal aorta was better than or equal to group B.
The negative effect of low kVp scanning is the increase in image noise. To reduce image noise and improve the CNR of blood vessels, double-low CTA should be combined with iterative reconstruction (IR). The ASIR-V applied in this study is a multimode iterative reconstruction algorithm, which can significantly reduce image noise [28,29], balance image noise against spatial resolution, and improve image CNR and image quality. However, the pre-ASIR-V will take part in the current modulation of the automatic tube. Higher weight will greatly reduce the tube current, but increase the image noise. Therefore, this study set the pre-ASIR-V weight of both the research group and the conventional group to 50% uniformly, while the post-ASIR-V only participates in the modulation of image noise. Some studies have shown that post-ASIR-V weight reconstruction with a higher application can significantly reduce image noise at the sacrifice of image resolution [25,30], affecting the clarity of image tissue, which makes the image appear flaky or shows plastic artifacts, thus affecting subjective observation of the image . Even if the noise value of the measured image is very low, it will not help to improve the subjective quality [32,33]. Therefore, to avoid the above situation and ensure high image quality, the weights of post-ASIR-V in the 2 groups in this study were set to the rate of 50%, which is commonly used in clinical inspections.
There are some limitations of this study. Firstly, this study only enrolled patients with BMI ≤27 kg/m2, and the feasibility of reducing radiation dose and contrast dose in patients with higher BMIs will be studied in the future. Secondly, 50% ASIR-V was applied in each group, and the relationship between tube voltage and ASIR-V reconstruction percentage was not explored. Thirdly, the results showed that the vascular attenuation values of the A1 and A2 groups reached 626 and 521 HU, respectively, which was significantly higher than that of the 120 kVp group, indicating that further reducing contrast dose is possible during 70 and 80 kVp.
BMI-adapted individualized kVp abdominal CTA significantly reduced overall radiation dose and contrast media intake while providing excellent image quality.
FiguresFigure 1. Comparison of MIP using conventional CT scanning at 120 kVp and BMI-adapted individualized kVp at 70 kVp. (A) Image of a 65-year-old female patient with BMI of 20.5 kg/m2 using 70 kVp tube voltage and 300 mgI/kg contrast dose. (B) Image of a 50-year-old female patient with BMI of 20.3 kg/m2 using 120 kVp tube voltage and 500 mgI/kg contrast dose. All images had 5 points in diagnostic confidence score. Figure 2. Comparison of MIP using conventional CT scanning group at 120 kVp and BMI-adapted individualized group at 80 kVp. (A) Image of a 62-year-old male patient with BMI of 22.8 kg/m2 using 80 kVp tube voltage and 300 mgI/kg contrast dose. (B) Image of a 67-year-old male patient with BMI of 23.0 kg/m2 using 120 kVp tube voltage and 500 mgI/kg contrast dose. The 80 kVp CT reduced the radiation dose in abdominal CTA while showing comparable or superior image quality. Figure 3. Comparison of MIP using conventional CT scanning group at 120 kVp and BMI-adapted individualized group at 100 kVp. (A) Image of a 62-year-old male patient with BMI of 25.1 kg/m2 using 100 kVp tube voltage and 300 mgI/kg contrast dose. (B) Image of a 53-year-old male patient with BMI of 24.9 kg/m2 using 120 kVp tube voltage and 500 mgI/kg contrast dose.
TablesTable 1. Comparison of patient characteristics between 2 groups. Table 2. Subjective score criteria of image quality. Table 3. CT values of arteries in each group were measured (χ̄;±s). Table 4. Comparison of objective parameters in abdominal CTA (χ̄±s). Table 5. Comparison of subjective scores of abdominal CTA between 2 groups. Table 6. Comparison of radiation dose and contrast agent between 2 groups (χ̄±s).
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