Coronary CT Angiography: Protocols

Contrast Media Optimization

James A. Brink, M.D.

Yale University
School of Medicine
 Cardiac CT Angiography

• Intravenous Contrast Material

• Flow Rate
• Concentration
• Type
• Duration (Volume)
• Scan Delay
Iodine Concentration in Blood/Tissue
800

700 120 Kvp

600 137 Kvp

500

400

300

200

100
25 HU per mg I / ml
0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Tissue Concentration
Concentration (I mg/cc) (I mg/ml)
Peak Enhancement vs. Flow Rate

Computer
Simulation
350

300
Increase in blood
250
flow caused by
the injection
200

150
Injection
Duration
100

50
Recirculation
0

0 5 10 15 20 25 30 35

Time after the start of injection (sec) Courtesy of Ty Bae

 Injection Duration
Porcine Model Computer Simulation
350 350
Aorta Enhancement (HU)

300 300
1-sec injection

Aortic Enhancement (HU)

3-sec injection
250 250
5-sec injection
200 200 8-sec injection
12-sec injection
150 150
20-sec injection
30-sec injection
100 100

50
50

0
0
0 5 10 15 20 25 30 35 40
0 5 10 15 20 25 30 35

Time after the start of injection (sec) Time after the start of injection (sec)

Bae KT. Radiology 2003;227:809-816

Duration
(Volume)
 IV Contrast for CTA

Injection Duration = Scan Duration

 350 Injection
Duration
300
1-sec
Aortic Enhancement (HU)

250 3-sec
5-sec
200 30 sec 8-sec
4DCT 12-sec
150
8 sec 20-sec
16DCT 30-sec
100

50

30 sec
8 sec
0

0 5 10 15 20 25 30 35 40
4DCT
16DCT
Time after the start of injection (sec)
 350 Injection
Duration
300
1-sec
Aortic Enhancement (HU)

250
8 sec 3-sec
16DCT 5-sec
200
8-sec
12-sec
150
8 sec 20-sec
16DCT 30-sec
100

50

8 sec
0

0 5 10 15 20 25 30 35 40
16DCT
Time after the start of injection (sec)
 IV Contrast for CTA

SDCT and 4DCT:

Injection Duration = Scan Duration

16DCT and 64DCT:

Injection Duration = Scan Duration + 10
 Saline Flush

• Facilitated with double-barrel

injector
• Eliminates messy loading of
saline on top of contrast in
single-barrel systems
 Saline Flush

• Eliminates excess contrast in tubing

• Flushes contrast from peripheral veins
into central veins
• Permits reduction in contrast volume by
about 20 to 40%
• Reduces beam hardening artifact in RCA
 64DCT – Uni Flow
• 2 Injection Phases:
• Contrast
• Saline
• Less contrast material, but no visualization
of right heart w/ dilute contrast
• Better definition / segmentation of left
heart and coronary arteries
64DCT – Uni Flow
 64DCT – Uni Flow (Yale)

• 2 Injection Phases: (Iodixanol 320, 5ml/s)

• Contrast 70 ml (14s)
• Saline 30 ml (6s)
• Scan duration = 3-5 sec
• Injection duration = 14 sec
• Injection duration = Scan duration + 10 sec
 350
Injection
Duration
300
1-sec
Aortic Enhancement (HU)

250 3-5 sec 3-sec

64DCT 5-sec
200
8-sec
12-sec
150
20-sec
100
30-sec
14-sec
50

0 5 10 15 20 25 30 35 40
3-5 sec
64DCT
Time after the start of injection (sec)
 64DCT -- Dual Flow

• 3 Injection Phases:
• Contrast
• Contrast + Saline
• Saline
• Permits visualization of right heart and
interventricular septum w/ dilute contrast
 64DCT
Dual Flow
64DCT -- Dual Flow

RCA LAD LCX

 64DCT -- Dual Flow (Yale)
• 3 Injection Phases: (Iodixanol 320, 5ml/s)
• Contrast 60 ml (12s)
• Contrast(60%) + Saline(40%) 50 ml (10s)
• Saline 40 ml (8s)
• Scan duration = 3-5 sec
• ‘Effective’ Injection duration = 18-22 sec
‘Effective’ ID = SD + 15 sec
 ‘Effective’
350
Injection
Duration
300
1-sec
Aortic Enhancement (HU)

3-5 sec
3-sec
250
64DCT
5-sec
200
8-sec
12-sec
150
20-sec
100
30-sec

50

0 3-5 sec
0 5 10 15 20 25 30 35 40
64DCT
Time after the start of injection (sec)
 64DCT – Dual Flow

• Right heart visualization

• Right heart mass
• Valve disease
• Prolonged injection duration:
• Triple Rule-Out
• Complete thorax (CABG)
64DCT – Dual Flow – Triple R/O

Prospective Gating

(100 kV; 5-7 mSv)

Scan Delay
 Scan Delay for Cardiac CTA
• Scan Delay
• May be fixed for patients presumed to
have normal cardiac output - risky
• Pitfall
• Abnormal cardiac output --> marked
delay in vascular enhancement
• test bolus or bolus tracking
 Cardiac Output --> Aortic Enhancement
c.o. = 25%
400

c.o. = 50%
350

c.o. = 100%
300
c.o. = 200%
250

200

150

100

50

0
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Time (min)

Computer Simulation, 5ml/sec. Bae, Heiken, Brink. Radiology Radiology 1998; 207:657-662
 Test Bolus

• Measure circulation time

• 20 ml @ 5 ml/sec (4 sec inj.)
• Scan at carina (Asc. Aorta & PAs):
• 10 - 30 sec q 1-2 sec
• Plot enhancement curve and find peak
• If no peak, change arm position, repeat
 Test Bolus

80

60

40
4 sec
20
4DCT 64DCT
0
14 16 18 20 22 24 26 28 30 32 34

Time (sec)
 Timing for Dual Flow 64DCT CCTA ‘Effective’
350
Injection
Duration
300

Peak + 4-8 sec 3-5 sec 1-sec

Aortic Enhancement (HU)

250 64DCT 3-sec

5-sec
200
8-sec
12-sec
150
20-sec
100
30-sec

50

0 3-5 sec
0 5 10 15 20 25 30 35 40
64DCT
Time after the start of injection (sec)
 Bolus Tracking

• ROI in aorta (usually descending aorta)

• Low-dose monitoring scans q 1-2 sec
• Trigger when enhancement > 100 HU
• Absolute value of 150 HU
• Add delay to initiate scanner, breath-hold
patient, and allow adequate enhancement
 Timing for Dual Flow 64DCT CCTA ‘Effective’
350
Injection
Duration
300
Contrast + ‘Eff’ Inj - Scan 1-sec
Aortic Enhancement (HU)

Arrival Duration3-5 sec

Duration 3-sec
250 64DCT
3-5 sec 5-sec
200
64DCT 8-sec
12-sec
150
20-sec
100
30-sec

50

0 3-5 sec
0 5 10 15 20 25 30 35 40
64DCT
Time after the start of injection (sec)
 Triple Rule-Out: Test Bolus

Scan delay is mid-point between time to peak in PA and Aorta

Triple Rule-Out: Dual Flow 64DCT ‘Effective’
Injection
Duration:
Pulmonary 20 sec
Aorta
Artery
10 sec
64DCT

10 sec
16 25 36 45 64DCT
 Cardiac CTA: Protocol Development
• Technique • 64DCT Uni Flow
• Flow Rate • 5 ml/sec
• Concentration • 320-370 mgI/ml
• Volume • 70(100%), 30(NS)
• Scan Delay • Test Bolus + 4-8 sec*
* Bolus Tracking:
Contrast Arrival + Injection Duration - Scan Duration
 Cardiac CTA: Protocol Development
• Technique • 64DCT Dual Flow
• Flow Rate • 5 ml/sec
• Concentration • 320-370 mgI/ml
• Volume • 60(100), 50(60/40), 40(NS)
• Scan Delay • Test Bolus + 4-8 sec*
* Bolus Tracking:
Contrast Arrival + Injection Duration - Scan Duration