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For personal use only; all rights reserved

Triphasic
Helical
CT of the Kidneys:
Contribution
of Vascular Phase Scanning
in Patients Before Urologic
Surgery
OBJECTIVE.

Brian R. Herts1
Deirdre M. Coil1
Michael L. Lieber2
Stevan B. Streem3
Andrew C. Novick3

ing

vascular

The purpose
phase

scanning

MATERIALS
renal

by two

ence

of vein

subjective

independent

of these

RESULTS.
square

system
was made

on the

arteries

and renal

coxons

rank

renal

vascular

use of a small

number
were

The subjective
were

contrast

The

before

and

arteries

and

veins

for each

scan

phase

fbr

significantly

more

often

scores

11r the

visibility

the

phase

planning

for urologic

riphasic

helical

surgery

of the kidneys

CT

amount
needed

parenchymal

phase

has

pose

imaging)

renal

masses 11-3].

after revision

1998.
1 Department of Radiology, Desk Hb6, The Cleveland Clinic
Foundation, 9500 Euclid Ave., Cleveland, OH 41495.
Address correspondence to B. R. Herts.
2Department
Foundation,

of Biostatistics,
Cleveland,

3Department

The Cleveland

OH 41495.

of Urology, The Cleveland

Cleveland, OH 41495.
AJR

The corticomedullary

American

735-1 273
Roentgen

AJR:173, November

and renal vessels. which

Clinic Foundation,

lature

4-6].

identification

before

urologic

surgery.

ureteropelvic

repair.

nephron-sparing

neoplasms

[7-12].

tim-

<

.00()l

for

Ray Society

1999

addition of a corticomedullary
in an increase
in radiation

scans.

rank sum

despite

is clinically

the

test.

of the kidin patients

important.

study

was

a vascular

dition

to standard

phase

contrast-enhanced

the va.sculature
limited

urologic

renal

unenhanced
CT

to

to identify

The examination

undergoing

patients

when

scan in adand parenchymal

CT

scans

of the kidneys.

surgery

the value of

to evaluate

phase

Cf

befire

this information

is most

ureter()pelvicjunction

obstruction.

ne-

obstruction

rather

for
than

because

phase
to

Wil-

renal va.scu-

surgery

CT angiography

useful clinically-specifically.
beftre nephronsparing surgery. donor nephrectomy.
or repair of

renal

the

of

the

scan results
patient,

Materials

the

and Methods

Tripha.sic

paren-

chymal
phase scans are alsc used for two-dimensional
multiplanar
and three-dimensional
renderings

of this

obtaining

was

chirenal

can be used

such as donor

junction

Vascular

unen-

scan of the

has similar

scans.

of anomalous

phrectomy.
and

from

A vascular

to corticomedullary

scan

mischaracter-

pseudolesions

or create

kidneys
to assist

phase

can mask lesions,

medulla

small

increased contrast differential

between
the yessels and the background
113. 141. However.
the

1999:173:1273-1277

0361-803X/99/1

Clinic

particularly

hanced
ing delay

Presented at the annual meeting of the American

Roentgen Ray Society, San Francisco, April-May

masses.

and charac-

.05.

<

of film used and archived. and the time

to review the images. Theretire.
the pur-

and

alone, however,

Received February 23, 1999: accepted

May3, 1999.

anatomy

corticomedullary.

of

ize lesions.

vascular

(unenhanced,

been shown to increase the detection

terization

when

87 kid-

of the

CONCLUSION.
Triphasic
renal CT better reveals
the artery
and vein anatomy
ney than does parenchymal
phase imaging
only. Triphasic
helical CT is indicated
undergoing

Cor-

of the collecting

phase

Wilcoxons

(p

scans (p

of the filling

parenchymal

.0001

<

in 67 of the

findings

on the vascular

higher

with

system.

20 kidneys.

for the visibility

each scan (p

the pres-

along

and collecting

or angiographic

higher

significantly

bolus

of renal

subjective

scores

phase

from tripharetrospective

recorded

seen

of perlbrm-

surgery.

of the vasculature

were

scans.

benefits

and parenchymal

and vascular phase images

evaluated
in a randomized.

in the remaining

arteries

phase

the potential

to unenhanced

for urologic

surgical

were significantly

veins

sum test).

and renal pelvis

system

with
review

by consensus

Accessory

test)

The

anomalies

score of the visibility

findings

and was made

neys

being examined

observers.

or collecting
10-point-scale

relation

in addition

AND
METHODS.
Parenchymal
CT of 50 patients
were sequentially

helical

fashion

was to evaluate

the kidneys

CT in patients

contrast-enhanced
sic

of this study

of

consecutive
of

the

Thirty

renal

vasculature

underwent

surgery.

nation

patients
of

scans

fr

and

collecting

scanning

kidney

underwent
vessels

ureteropelvic

of 87 kidneys

evaluated

I 2 underwent

as a possible

of crossing
pair

CT
were

patients

spanng
eight

helical
patients

before

scanning

possible

junction

system.

before

transplant

scanning

in 50

the depiction
nephronfr

exanii-

donor.

and

for examination
endourologic
obstruction.

reThirty-

1273

Herts
both kidneys.
11 patients
had
and two patients had only a left
kidney. Twenty-one
women and 29 men who ranged
in age from 19 to 80 years (mean. 50 years) cornprised the study group.
seven

patients

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only

had

a right

kidney.

CT Technique

All

patients

triphasic

renal

neys

were

scanned

protocol.

was performed

a pitch

with

of I at 120 kVp

time of 0.75
using

A vascular

next

at a rate of 4 mllsec

also

abdorni-

partial fill-

allowed

system.

phase

scan was obtained

tion of I 20 ml of contrast
see: a collimation

material

was used

after

to cover

speed

of 3-6

from the supe-

the region

artery through

an injec-

at a rate of 4 ml!

and a table

of 3 mm

nor mesenteric

for a scan

of the upper

test injection

ing of the collecting

mA

was performed

material

enhancement

nal aorta. The

following

then the vascular phase scans were sequentially evaluated for each patient by two radiologists.
The evaluation of the parenchymal and then vascular phase scans
was performed sequentially because the goal of this
study was to evaluate the relative contribution of adding the vascular phase scan to the Standard unenhanced
and parenchymal phase CT scans ofthe kidneys. Each
radiologist

the proximal

reviewed

cases

in a random

order

and was

of angiographic or surgical findings.

The number of renal arteries and the presence

type

of renal

vein

and

collecting

system

Correlation
with angiographic
(33 kidneys in 20
and surgical
findings
(34 kidneys
in 30 patients) for the number of renal arteries. veins, and dupatients)
plicated

and

anomalies

were recorded for each CT scan phase. In addition,

the conspicuity
of four anatomic structures each on
the right and left was rated subjectively
using a 10point scale with 10 as the highest rating (1 = not visualized.
10 = well visualized).
The four structures were
the renal artery origins.
including
accessory
arteries:
the segmental renal arteries: the renal veins: and the
filling of the collecting system, including the calices,
infundibulum.
renal pelvis. and proximal ureter.

collecting

remaining
omy
with

system

was

available.

20 kidneys (12 patients),

was determined

radiologist

by consensus

observers.

angiograms,

The

surgical

For

the vascular
review

total

number

results,

and

the
anat-

by the two
of patients

consensus

re-

studied
because
some patients underwent
both angiography
and surgery. In addition, four patients with bilateral
renal tumors underwent surgery on both sides used
for correlation, and 13 ofthe 30 patients examined for
nephron-sparing
surgery had a solitary kidney. There
was discordance
between angiographic
and surgical
results in one case: A third renal artery at surgery in a
view

unaware

of 5 mm and

a collimation

sec. A test injection

for the maximal

the

CT of the kid-

and 240-280

20 ml of contrast

mm/sec

using

Unenhanced

et al.

findings

exceeds

the number

kidney

transplant

donor

by one

observer

on angiography

two observers
affect

patient

of patients

was called

on CT; however.

an early
and

branch

by one

these findings

of the

did not

treatment.

common

iliac arteries. The delay time for this scan phase was 5
sec more than that used for the test injection to ensure
enhancement
of the renal veins and upper pole branch
vessels. The approximate
scan delay for this phase
was 35 sec. Although

this scan does

not substantially

differ from a corticomedullary

phase scan, this scan is
referred to as a vascular
phase scan because
it is
timed for the vessels. In a few patients. the test injection and contrast
bolus were administered
at a rate of
3.5 mI/sec. Scan parameters
were 120 kVp, 240-300
mA. and a 0.75-sec scan time. The pitch was chosen
to keep the total scan time equal to the duration of the
contrast injection-that
is. approximately
30 sec.
A parenchymal
phase scan was obtained
through
the kidneys

using

hanced

scan

for renal

mation

of 5 mm.

mA.

and

lay

time

material
scan

a scan
from

the same
a pitch
time

the

of 0.75

start

sec. The

a colli-

kVp.

240-280

estimated

injection

de-

of contrast

of the parenchymal

phase

I 20 sec.

All scans were obtained

(Siemens

1. 120

of the

to the beginning

as the unen-

characterization:
of

was approximately

scanner

parameters

lesion

on a Somatom

Medical

Systems.

Fig. 1.-Multiple right renal arteries in 55-year-old man with right renal neoplasm.
A and B, Vascular phase (A) and parenchymal phase (B)triphasic
renal CT scans show main (straightarrow)
and
accessory
renal artery (curved arrow, A) arising from aorta at same level. Note that accessory
right renal artery
was not identified as separate vessel on B.

Plus 4 CT
Forchheim,

Germany).
All images were reconstructed
with a
SOC/c collimation
overlap ( 1.5-mm table increments
for a 3-mm collimation:
2.5-mm table increments
for a 5-mm collimation).
Unenhanced
and parenchymal phase scans were reconstructed
at a standard
field of view with a standard
kernel. AB5O. Vascular
phase scans were reconstructed
with a targeted field
of view of between
250 and 300 mm and using our
standard

or sm(x)ther

imaging

kernel

AB5O.

AB4O,

or AB3O depending

on the region of interest (one or

both kidneys)
and on image
noise. on the basis of
body habitus.
Oral contrast material was variably administered
depending
on how the patient was scheduled: whenever possible, instructions were given to
not administer oral contrast material.
Image

Review

All images were reviewed

on a soft-copy
imaging
workstation (MagicView
1000: Siemens Medical Systems. Forchheim.
Germany). The parenchymal
and

1274

Fig. 2. -Multiple
right renal arteries in 38-year-old
female potential kidney donor.
A and B, Vascular phase (A) and parenchymal
phase (B) triphasic
renal CT scans show small accessory
(arrow) on A that is only faintly seen on B. Both observers
being greater on vascular phase scans.

subjectively

scored

visibility

of this accessory

artery
artery as

AJR:173, November

1999

Triphasic

Helical

CT

of the

Kidneys

umber
ofVascular
Anomalies
Correctly
Identified
by Each Observer
irenchymal
and Vascular
Phase Im* es of87 Kidneys in 50 PatIents

sides.

on

observers

Both

accessory

renal

correctly

arteries

identified

more

on the vascular

phase

scans (Figs. I and 2). The difference

between the
scan phases was statistically significant
(p < .02),
whereas

the difference

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Nine

( I 8%)

anomalies.

(p > 12) (Table

of 50 patients

Six patients

renal

Six patients

revealed

on vascular

phase

images

signifi-

servers

servers

identified
phase

Subjective

Scoring

Renal

parenchymal

Results
Accuracy

justment

correlation

ies.

considered

1 1 patients

was

made

for

intrapatient

between
kidneys. The p values were
statistically significant
if less than .05.

Scoring

ftI:1I*Subjectlve

of Renal Vasculature

renal arteries

Accessory

Vein,

Artery,

The

segmental

were on the right in

and on the left in 10 patients.

with accessory

Collecting

and

includ-

renal arter-

renal arteries

and 2.8 points

higher

with

of 2.4

for the vascular

phase

A and

observer

difference

in the

2). The

ference

in the rating

Observer

Site

Parenchymal
Phase

Renal arteries
Renal artery

segments

Renal veins
Collecting

system

Observer

Vascular
Phase

#{176}

Parenchymal
Phase

different

(p

Comparison
in Subjective

9.5

<

.001

4.7

7.1

<

.001

6.0

8.8

<

.001

7.3
7.4

8.6
5.9

<

.001

8.7

9.4

<

.001

8.6

6.9

<001b

were greater

for the vascular

phase scans except

not visualized,

10

well visualized).

for the collecting

Inatornic
4;
I

#{176}

7.3

the values

values

Vascular
Phase

.001

bAll statistically

significant

gores

<

of the

3).

terobservsr

8.9

Note-All
scores are on a discrete 10-point scale with 10 being the highest score (1
All values were statistically significant at p < .05.

interobserver

was not significantly

.20) (Table

Anatomy

5.9

<IJt1b

B, respec-

for the conspicuity

arteries

renal

if Differences

Anatomic

was

scores

.0001 ) (Table

<

(p
of the

for both observers

significant,

(p

B. respectively
in the scoring

difference

also statistically

segmental

arteries on both

System

significant

of the main

rating for the conspicuity

of
the renal artery origins was significantly
greater
for observer
A (p = .03). The interobserver
dif-

Overall,
19 (38%)
of 50 patients
and 21
(24%) of 87 kidneys
had accessory renal arter-

ing three patients

of Renal

< .0001).

tively
of the Identification

statistically

A and observer

scans for observer

Statistical
analysis of the subjective
scores was
performed
using the Wilcoxons
rank sum test.
The values for the right and left kidneys for patients with both kidneys were combined
and an ad-

dupli-

scans of 3.0 and 2.2 points

phase

for observer

StatisticalAnalysis

with

on the parenchymal

seen for both observers,

with a mean
in scores
between the vascular
and

ies was

by both

renal

Both observers

patients

in the scoring

difference

cava.

left

images.

arteries-A

difference

Fig. 3.-Multiple
right renal veins in 54-year-old
man with right renal neoplasm.
A, Vascular phase triphasic renal CT scan shows second right renal vein (arrow) entering
inferior
vena
B, Parenchymal phase triphasic renal CT scan shows second right renal vein that was misinterpreted
observers as artery curving behind inferior vena cava (arrow).

retroaortic

two

and vascular

whereas

correctly
phase
images

were seen by both ob-

systems

collecting

re-

by both obwere

on both sets of images.

correctly
cated

and

left

right

images.

phase

this anomaly
parenchymal

(Fig. 3). Circumaortic

veins in three patients

re-

left re-

multiple

identified

on the vascular

four patients with

identified
on the

vein

right

had retroaortic

with

nal veins were correctly

Note-For
both observers, the number of patients with multiple renal arteries
cantly exceeded the number revealed on parenchymal phase images I p < .021.

renal

had circumaortic

and one patient

veins.

had

observ-

1).

had multiple

nal veins, two patients

nal veins.

the two

between

ers was not significant

system.

..

Renal arteries

Mean Score Difference

..

Site7

30

#{246}ollectgt
Note-The
the mean score

PbserverB

.-4,;

22

03C

81I

mean score differences

for the vascular

were calculated

as

phase minus the mean score

for the parenchymal

phase for each observer.
Observer
B
was the more experienced observer. The mean score difference was statistically
significant
at p < .05.

AJR:173, November

1999

1275

Herts

Renal

difference

spicuity

of

phases

in

the

the

renal

for both

difference

phase

points

for observer

tively.

The

scans

scan

(p < .0001).

The

is performed

the vascular

and

detection

0.7

for

were

interobserver

significantly
.002)

between

B, respec-

difference
for

veins

observer

was

(p

<

3).

Collecting
system-A
statistically
significant difference
in the scoring of the renal collecting
for

system

both

between

scan
with

observers,

phases
the

seen

was

parenchymal

phase scans rated significantly

vascular
phase scans (p <

.0001)

The

differences

for the conspicu-

ity

between

phase

in the scores

scans

the

parenchymal

were

1.5 and

server A and observer

terobserver
difference
conspicuity
significantly

and

B, respectively.
in

the

the
2).

rating

of the collecting
system
different
(p > .8 1 ) (Table

These

ability

of helical

to scan abdominal

organs

during

a vascular

For

the

Other

renal

in

cause

the

vessels

junction

test.

because

location

CT

crossing

would
renal

branches

segmental
total

success

nephrectomy

sparing surgery.
Previous
studies

with en-

focused

on its use

or open

ization of lesions,
potential
kidney

repair

[21, 22]. A 42%

The infor the

endourologic
repair is reported
in patients
with
vessels crossing at the ureteropelvic
junction,
whereas
a 90% success
rate is reported
using

vicjunction
anatomic

an open

or antegrade

compared

urologist

considers

not

CT

is the

during

differ-

phase of

than

procedure

percutaneous

approach
CT
vessels

in choosing

Similarly,
the side
chosen to simplify

prove

the

chances

for

are

less

important

for

nephron-

of triphasic

of crossing

vessels
not,

to specifically

evaluate

whether

unless

scan provides
parenchymal

better anatomic
phase scan.

trans-

in ureteropel-

with the
this study

the parenchymal
images
images. To our knowledge,

is the first

Our

results

the

suggest

detail

that

the

phase

than

most

signifi-

plant. Short renal veins, multiple

veins, and
multiple
arteries
are technically
more difficult to anastamose
and may compromise
the
transplant;
therefore,
if an accessory
renal ar-

present

enhancement
of the liver. In the abdomen,
triphasic
helical CT adds value to imaging of

tery

rated the conspicuity

of the origins
nal artery
and segmental
arteries

the liver,

Regarding
nephron-sparing
surgery,
some
surgeons perform
an avascular
technique
for

on the vascular
collimation

of 3 mm and at peak vascular

large

hancement

likely

ports

and pancreas.

kidneys,

have

shown

value because

has added

tion and characterization

As expected,
these
in certain
patient

Previous

the arterial

that

phase

rescan

of its improved

detec-

[1-3,

15-18].

oflesions

benefits are more important

populations;
for example,

In the kidneys.

phase imaging
and enhanced

shown to be both

tal and beneficial

for lesion

acterization
I 1-4].
This study evaluates
phase

imaging

the point
tions-namely,

detection

the benefit

for presurgical

of view

of specific
nephron-sparing

pair of ureteropelvic

1276

of vascular

to the standard
unenhanced
thin-section
helical
imaging

has been

protocol

the addition

junction

the

side

or hilar
kidney.

the

surface

urologist

cooling

of

identifies

and

of vascular
from
indicareand

the
of

The

depiction

the identification

increased

of the third
diation

risk

scanning

dose

or cost.
phase

to the patient
6 rad

(0.06

the estimated
Gy)

pected

conventional

from
[0.05

triphasic

renal

the patient

may

nal arteriography

addition

increases

the ra-

for a total
Gy)

for

dose

helical

be ex(5

Furthermore,

CT

be subject

is not

to the risks

and venography.

if

performed,
of re-

Obtaining

images.

accounts

of renal

25%

of

Scanning

to replace

conventional

systems

phase
and

than the vascular

and
angiog-

angiography
scans

aided

in
but

depicted collectmore consistently

phase scans despite

bolus.

is also

vein anomalies,

scans

anomalies

enresults.

vasculature

of renal

the parenchymal

at a

for these

for these clinical

indications.
Adding
vascular
phase CT

ing

of the reas greater

using
two-dimensional
reformats
for CT

a test contrast

dose

angiography

Gy/min]).

of
CT

each

additional

is less than would

of 2 rad (0.02
rad/min

The

phase

critical
when
three-dimensional

without

scan. However,

surgery,

side,

raphy

approximately

obstruction,

one

transplantation.

and nearly

the kidneys studied. Many accessory

arteries
were either seen better or seen only on the
vascular
phase
scans.
The observers
also

the number and position

of accessory
vessels
and early branches facilitates
the surgery.
Performing
triphasic
helical
CT is not

and char-

urologic

for

after

The

on

are

be chosen

tumors

detrimen-

planning

veins

may

clamps
the renal arteries
and identifies
veins before surface
cooling.
Knowledge

triphasic
helical CT of the liver has maximum
benefits
for patients
whose liver lesions show
hypervascular
enhancement
properties
[19,
201.

or multiple

the

of the renal
arteries
were

organ enhancement,
and scanning
during what
was once referred
to as standard
postcontrast
imaging and is now referred to as parenchymal
phase of enhancement
or portal venous phase

other

of patients

objectively

vascular

cant benefit
is in the evaluation
artery
system.
Multiple
renal
in 38%

of
the

8-12, 15]. These

however,
directly

and subjectively

of the

character-

and

[1-5,

for

success

CT have

renal

the anatomic examination

transplant
donors,
and

visualized

of donor
nephrectomy
the surgery
and im-

berenal

than

are not

en-

included

triphasic

for detection

obstruction
studies
have

vascular

the

and

planning.

in patients
with
the renal arteries

appropriate

during the endourologic

procedure
doscopic
sonography
is used.
is

identification

[21, 22]. The

results

is most

Crossing

rate using

success

that

vessels

not

of

little relevance
In addition,

for

complications

were

have
stones.

and

have a lower

bleeding

renal

presurgical

use

mdi-

institution

scanning
may not always have clinical
relevance. For example,
the depiction
of vessels

is rewith

for

protocols

time.

indications

of

routine

at the ure-

patients

at our

common

system

ways

been established by reurography,

retrograde

because

most

recon-

and reading
to the urologic

identification

example,

junction obstrucbefore repair, the

or the Whitaker

at this

mentioned

require

as increased

usage,

our study

these are the

also

vasculature

are in many

indications.

diagnosis
has usually
sults from
excretory

teropelvic

cations

such

film

We limited

pyeloplasty

was
3).

or arterial

reasons

pyelography,

time,

struction

dourologic

ent phases of enhancement.

Triphasic
helical
CT usually
implies
unenhanced
imaging,
scanning

but

the scan adds costs

collecting

patients with ureteropelvic

tion who are being examined

patient.
advantage

renal

system.

latter

vessels

for the

of lesions

of the

important

which
clear

not only

or characterization

more

the use

for ob-

Discussion
One

patients

the examination

rate and more

vascular

1.7 points

for these

quested to identify

than
(Table

higher

Studies describing

for these
indications
include
CT protocols [8, 10, 12]. CT

and collecting

in the rat-

of the renal

greater

(Table

1 .3 and

A and observer

ing for the conspicuity

donor nephrectomy.
of helical
CT
triphasic
helical

veins

observers

sig-

for the con-

score

in scores between

parenchymal

Downloaded from www.ajronline.org by 114.79.28.251 on 12/03/14 from IP address 114.79.28.251. Copyright ARRS. For personal use only; all rights reserved

found a statistically

veins-We

nificant

et al.

Compression

the use of
bands

for

distention
of the renal pelvis and collecting
system may improve
visualization,
but the collecting
ized

system

would

on parenchymal

still likely
phase

be best visual-

scans.

Our study has some limitations.

jective
evaluation
was included

First, a suband therefore

AJR:173, November

1999

Triphasic

observer

bias

though

discrete,

may

have

cluded-specifically,

Downloaded from www.ajronline.org by 114.79.28.251 on 12/03/14 from IP address 114.79.28.251. Copyright ARRS. For personal use only; all rights reserved

number

the

of renal

arteries

level

of experience

may

The

more

tients.

accessory

data

have

al-

were

identification

in-

of the

veins.

Second,

affected

results:

observer,
renal

although

Finally.

introduced.

and

experienced

saw more

been

nonsubjective

observer

arteries

the definition

pa-

of added

value is arbitrary,
we believe that the benefits
to this patient population
outweigh
the risks.
In summary,

the addition

of vascular

phase

scans to parenchymal
phase contrast-enhanced
images of the kidneys
showed a significant
benefit for the identification
of renal arteries and renal
the collecting

system

parenchymal

phase

CT of the kidneys
alization

images.
artery

for presurgical

on the
helical

Triphasic

is recommended

of the renal

is important

and quantification
veins. As expected,

was best identified

when

3. Szolar

DH.

Multiphasic
conspicuity
small

CT

Kammerhuber

visu-

and vein anatomy

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