Automatic Plaque Removal Using Dual-Energy Computed Tomography Angiography: Diagnostic Accuracy and Utility in Patients with Peripheral Artery Disease

Abstract

Background and Objectives: This study aimed to evaluate the utility and accuracy of dual-energy automatic plaque removal (DE-APR) in patients with symptomatic peripheral arterial disease (PAD) using digital subtraction angiography (DSA) as the reference standard. Materials and Methods: We retrospectively analyzed 100 patients with PAD who underwent DE computed tomography angiography (DE-CTA) and DSA of the lower extremities. DE-CTA was used to generate APR subtracted images. In the three main arterial segments (aorto-iliac segment, femoro-popliteal segment, and below-the-knee segment), the presence or absence of hemodynamically significant stenosis (>50%) and calcification was assessed using the images. CTA data were analyzed using different imaging approaches (DE-standard reconstruction image (DE-SR), DE-APR maximum intensity projection image (APR), and DE-SR with APR). Results: For all segments evaluated, the sensitivity, specificity, and accuracy for detecting significant stenosis were 98.16%, 81.01%, and 89.58%, respectively, with DE-SR; 97.79%, 83.33%, and 90.56%, respectively, with APR; and 98.16%, 92.25%, and 95.20%, respectively, with DE-SR with APR. DE-SR with APR had greater accuracy than DE-SR or APR alone (p < 0.001 and p < 0.001, respectively). When analyzed based on vascular wall calcification, the accuracy of DE-SR with APR remained greater than 90% regardless of calcification severity, whereas DE-SR showed a considerable reduction in accuracy in moderate to severe calcification. In the case of APR, the degree of vascular wall calcification did not significantly influence the accuracy in the aorto-iliac and femoro-popliteal segments. DE-SR with APR achieved significantly higher diagnostic accuracy for all lower extremity segments in evaluating hemodynamically significant stenosis in patients with symptomatic PAD and transcended the impact of vascular wall calcification compared with DE-SR. Conclusions: APR demonstrated favorable diagnostic performance in the aorto-iliac and femoro-popliteal segments, exhibiting good agreement with DSA even in cases of moderate to severe vascular wall calcification.

The Clinical Utility of Lower Extremity Dual-Energy CT Angiography in the Detection of Bone Marrow Edema in Diabetic Patients with Peripheral Artery Disease

“…CTA has been widely recommended as the first-line examination for the evaluation of the extent and severity of PAD, effectively replacing DSA as treatment planning guidance [ 19 , 42 ]. While the current literature mainly focused on the advantages of DE-CTA in the evaluation of arterial lumen, in the estimation of arterial stenosis and in-stent patency evaluation, its ability to recognize lower limbs BME in diabetic patients with PAD has been poorly investigated [ 12 , 13 , 24 , 25 , 39 , 43 ]. The abnormal fluid signal within the bone marrow, routinely detected on MRI, is a nonspecific, yet important, finding suggestive of underlying bone inflammation in non-traumatic diabetic patients [ 33 , 36 , 40 , 43 , 44 ].…”

“…This mechanism allows different useful applications of DECT in PAD, also reducing iodine contrast medium dose and radiation burden [ 20 , 21 , 22 , 23 ]. Furthermore, DECT post-processing algorithms enable the removal of bone and the calcium content of highly calcified plaques, reducing “blooming” artifacts and obtaining a true CTA “luminogram” [ 18 , 24 , 25 , 26 ].…”

True Non-Contrast Phase versus Virtual-Non Contrast: “Lights and Shadows” of Dual Energy CT Angiography in Peripheral Arterial Disease

“…Moreover, post-processing algorithms allow the identification and removal of the calcium content of calcified plaques, obtaining a better evaluation of the contrast-enhanced vessel lumen, similar to DSA images [6,11,[27][28][29][30][31][32][33][34][35][36][37]. Imaging of arteries may benefit greatly from these DECT reconstructions.…”