Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • O r i g i n a l R e s e a r c h

Masuda et al.

CT Angiography of Suspected
Lower Extremity CTA of Patients With Suspected PAD

Vascular and Interventional Radiology

Original Research
Peripheral Artery Disease:
Comparison of Contrast
Enhancement in the Lower
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Extremities of Patients
Undergoing and Those Not
Undergoing Hemodialysis
Takanori Masuda1,2 OBJECTIVE. The objective of our study was to compare contrast enhancement on CT an-
Yoshinori Funama3 giography (CTA) images of the lower extremity in patients with suspected peripheral artery dis-
Takeshi Nakaura4 ease who did not undergo hemodialysis (HD) and patients who were scanned before or after HD.
Naoyuki Imada1 MATERIALS AND METHODS. We divided 287 consecutive patients who underwent
Tomoyasu Sato5 CTA of the lower extremity on a 64-MDCT scanner into three groups: group 1 patients (n =
151) were not dependent on HD, group 2 patients (n = 70) were dependent on HD and under-
Tomokazu Okimoto 6
went HD less than 24 hours after CTA, and group 3 (n = 66) were dependent on HD and un-
Kazuo Awai2 derwent HD less than 24 hours before CTA. We then compared the CT number in the pop-
Masuda T, Funama Y, Nakaura T, et al. liteal artery at the level of the patella on all CTA images. A cardiologist and a radiology
technologist visually evaluated the depiction of the descending genicular artery (DGA) on the
CTA images and assigned a visualization score.
RESULTS. The median CT number was lowest in group 2 patients (373 HU vs 429 [group
Keywords: contrast enhancement, contrast material, 1] and 418 [group 3] HU). The score for visualization of the DGA was significantly lower in
hemodialysis, lower extremity CT angiography, lower group 2 than in group 1 (p = 0.02) and group 3 (p = 0.04).
extremity peripheral artery disease CONCLUSION. At CTA, arterial enhancement decreases with the passage of time af-
ter HD likely because of the increase in intravascular volume. CTA that is performed within
DOI:10.2214/AJR.16.16810
24 hours after HD generates higher-quality images of the lower extremities than CTA that is
Received May 21, 2016; accepted after revision performed within 24 hours before HD.
November 11, 2016.
enal insufficiency and end-stage by HD. Because the volume extracellular flu-

1
Department of Radiological Technology, Tsuchiya
General Hospital, Nakajima-cho 3-30, Naka-ku,
Hiroshima 730-8655, Japan. Address correspondence to
T. Masuda (takanorimasuda@yahoo.co.jp).
2
Department of Diagnostic Radiology, Graduate School
of Biomedical Sciences, Hiroshima University,
Hiroshima, Japan.
3
Department of Medical Physics, Faculty of Life
Sciences, Kumamoto University, Kumamoto, Japan.
4
Department of Diagnostic Radiology, Graduate
School of Medical Sciences, Kumamoto University,
­Kumamoto, Japan.
5
Department of Diagnostic Radiology, Tsuchiya
General Hospital, Hiroshima, Japan.
6
Department of Cardiovascular Internal Medicine,
Tsuchiya General Hospital, Hiroshima, Japan.
Supplemental Data
Available online at www.ajronline.org.
AJR 2017; 208:1127–1133
0361–803X/17/2085–1127
© American Roentgen Ray Society
R
renal disease are often associat-
ed with peripheral artery disease
(PAD) of the lower extremities
[1], and the rate of lower extremity amputa-
tion is 10 times higher in patients undergoing
hemodialysis (HD) than in elderly patients
with diabetes [1–4]. Therefore, the early di-
agnosis and treatment of PAD in patients
with renal insufficiency are important to re-
tain their quality of life [5].
CT angiography (CTA) of the lower ex-
tremity, a noninvasive procedure, is widely
used to diagnose PAD [6, 7]. In patients un-
dergoing HD, the optimal timing of lower ex-
tremity CTA remains controversial. Accord-
ing to Younathan et al. [8], nonionic contrast
material can be administered safely to pa-
tients with end-stage renal disease who are
being maintained on HD and HD immedi-
ately after contrast administration is not
necessary. We, on the other hand, have oc-
casionally observed poor contrast enhance-
ment on CTA images of the lower extremity
in patients with PAD who are being treated
id (ECF) is increased in patients with PAD
immediately before HD [9, 10], their body
weight (BW) differs by approximately 5%
before and after HD [11]. We hypothesized
that the increased ECF volume before HD re-
sults in lower arterial enhancement at lower
extremity CTA in these patients. To test our
hypothesis, we compared enhancement in
patients who were not treated by HD and pa-
tients who underwent HD less than 24 hours
before or after CTA.
Materials and Methods
This retrospective study received institutional
review board approval. The requirement for in-
formed patient consent was waived.
Patients
Between January 2014 and December 2015,
293 patients with PAD suspected on the basis of
an ankle-brachial pressure index of less than 0.9
or intermittent vascular claudication underwent
lower extremity CTA at our hospital. None had
a history of allergic reactions to iodinated con-

AJR:208, May 2017 1127

 Masuda et al.

TABLE 1: Characteristics of Patients Who Were Not Dependent on Hemodialysis (HD) (Group 1) and of HD-­Dependent
Patients Who Underwent HD Less Than 24 Hours After CT Angiography (CTA) (Group 2) or Less Than 24
Hours Before CTA (Group 3)
Patients Not Patients Dependent on HD (n = 136) p
Dependent on HD:
Group 1 Group 1 Versus Group 1 Versus Group 2 Versus
Characteristics (n = 151) Group 2 (n = 70) Group 3 (n = 66) Group 2 Group 3 Group 3
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Shunt creation — — 0.19

Left — 6 11
Right — 64 55
Age (y) 73.0 (43.0–102.0) 70.0 (41.0–91.0) 72.0 (45.0–96.0) 0.06 0.41 0.64
Sex (no. of patients) 0.08 0.32 0.53
Male 76 45 39
Female 75 25 27
Body height (cm) 159.0 (135.0–179.0) 157.0 (143.0–175.0) 156.0 (142.0–178.0) 0.87 0.7 0.94
Actual BW (kg) 56.0 (36.5–106.0) 54.0 (34.0–84.0) 55.0 (32.0–83.0) 0.99 0.69 0.81
Dry BW (kg) — 53.0 (32.5–84.0) 53.6 (30.0–82.0) — — 0.12
Time interval between dialysis and CTA (h) 41.0 (41.0–67.0) 18.0 (13.0–19.0) < 0.01a
Body surface area (m2) 1.57 (1.10–2.20) 1.50 (1.20–1.90) 1.59 (1.20–2.00) 0.99 0.65 0.78
Body mass indexb 22.2 (17.7–33.1) 22.0 (14.4–32.9) 21.3 (14.6–31.5) 0.99 0.79 0.71
Estimated GFR (mL/min/1.73 m2) 61.5 (42.0–213.7) 5.3 (2.5–23.2) 5.6 (2.4–23.2) < 0.01a < 0.01a 0.42
Ejection fraction (%) 61.5 (33.0–90.0) 60.0 (33.0–80.0) 60.0 (27.0–75.0) 0.76 0.48 0.9
Contrast arrival time (s) 32.0 (21.0–64.0) 32.0 (22.0–60.0) 34.0 (21.0–64.0) 0.72 0.09 0.38
Note—Unless indicated otherwise, data are presented as means (range). Dash (—) indicates not applicable. BW = body weight, GFR = glomerular filtration rate.
aThe p values indicate that the difference is statistically significant.
bWeight in kilograms divided by the square of height in meters.

trast material. We excluded six patients with lower
leg amputation because the hemodynamics of the
lower legs may be different in patients with an am-
putation and those without an amputation. Of the
remaining 287 patients, 151 were not dependent
on HD (group 1), and 136 were dependent on HD.
Of the latter, 70 underwent HD less than 24 hours
after CTA (group 2), and 66 were treated by HD
less than 24 hours before CTA (group 3). None of
the group 1 patients had an estimated glomeru-
lar filtration rate (GFR) suggestive of renal failure
(estimated GFR  < 40 mL/min/1.73 m2). The pa-
tient characteristics are listed in Table 1.
Patient data were used for post/hoc power anal-
ysis (power = 80%, alpha = 5%) to calculate the
sample size required per group with respect to the
study parameters. The numbers of patients in the
three groups were sufficient for the detection of in-
tergroup differences.
CT Protocol
All patients were scanned on a 64-MDCT
scanner (LightSpeed VCT, GE Healthcare). The
scanning range for lower extremity CTA was from
the top of the liver to the lower end of the feet in
the craniocaudal direction. The scanning param-
eters were 0.5-second rotation time, 1.25-mm de-
tector-row width, 0.516 helical pitch (beam pitch),
41.2-mm/s table movement, and 50-cm scanning
FOV. The peak tube voltage was 100 kVp; the tube
current was changed using automatic tube current
modulation from 100 to 770 mA to maintain the
image quality level (noise index, 14). The scanning
length along the z-axis ranged from 30 to 40 cm
depending on the patient’s body size. The scan-
ning time ranged from 29.0 to 31.0 seconds.
Contrast Material Injection Protocols
The contrast material (iohexol [Omnipaque
300, Daiichi-Sankyo]) was injected through a
20-gauge catheter into the antecubital vein with
a power injector (Dual Shot, Nemoto-Kyorindo).
For the popliteal arteries, we acquired a test bo-
lus study at the patella level using a time-densi-
ty curve to determine the accurate scanning tim-
ing. The test bolus study was composed of serial
low-dose scans (100 kVp and 50 mA) that were ob-
tained without table movement; the interscan in-
terval was 1.0 second. The contrast material (15.0
mL) was IV administered at a rate of 3.0 mL/s and
was followed by the IV administration of 20.0 mL
of a saline solution at 3.0 mL/s.
Acquisition of the dynamic monitoring scans be-
gan 18.0 seconds after the start of the contrast ma-
terial injection. We placed an ROI in the popliteal
artery at the level of the patella to obtain a time-at-
tenuation curve. An attempt was made to maintain
a constant ROI area of approximately 7.0 mm2; the
range of ROI sizes was 3.1–12.6 mm2. The scanning
start time for each patient was defined as the con-
trast arrival time plus 5.0 seconds based on the time-
enhancement curves of the test bolus scan (Appen-
dix S1, which can be viewed in the AJR electronic
supplement to this article at www.ajronline.org).
For lower extremity CTA, contrast material
(85.0 mL) was administered IV at an injection rate
of 3.0 mL/s and was followed by the IV adminis-
tration of 20.0 mL of a saline solution at 3.0 mL/s.
Quantitative Assessment
On the lower extremity CTA images, we mea-
sured the CT number at five sites from the abdom-
inal aorta to the metatarsal artery—that is, at the
abdominal aorta at the third lumbar vertebral lev-
el, at the internal iliac artery at the hip joint level,
at the femoral artery at the center of the femoral
bone, at the popliteal artery at the level of the pa-
tella, and at the lateral malleolus at the dorsalis
pedis artery (Fig. 1).
We recorded the CT numbers of the bilater-
al arteries and calculated the mean. These mea-

1128 AJR:208, May 2017

 Lower Extremity CTA of Patients With Suspected PAD
surements were taken at the abdominal aorta at
the third lumbar vertebral level (level a), the ex-
ternal iliac arteries at the hip joint level (level b),
the femoral arteries at the middle of the femur
(level c), the popliteal arteries at the level of the
patella (level d), and the dorsalis pedis arteries
at the lateral malleolus level (level e). The sizes
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of the circular ROI cursors were approximately
5.0 mm 2 at levels a, b, and c and 2.0 mm 2 at lev-
els d and e.
Qualitative Assessment
A cardiologist and a radiology technologist
with 23 and 20 years of experience, respectively,
qualitatively evaluated the descending genicular
artery (DGA) on the 287 randomized maximum-
intensity-projection images. We selected the DGA
for qualitative analysis because the DGA usual-
ly has minor wall calcification, which makes eval-
uation easy. In contrast, major wall calcification
makes it difficult to evaluate the arteries below the
popliteal artery. The observers used the following
4-point scale to grade visualization of the DGA:
A score of 4 was assigned when the main trunk
of the DGA was completely visible and almost
all of its first branches were visualized; score of
3, the entire DGA was visible but its first branch-
es were ambiguous; score of 2, part of the DGA
was visible; and score of 1, the DGA was not vis-
ible (Fig. 2). Disagreements were resolved by con-
sensus. The images were presented to the review-
ers on a digital PACS at a diagnostic workstation
(Advantage Windows workstation, version 4.2,
GE Healthcare).
Measurement of Patient Weight
In patients being treated by HD, we defined
dry BW as the BW measured after HD [12] and
used the BW listed in the electronic health record
(BF-629, Tanita).
We defined actual BW as the BW measured just
after lower extremity CTA. We measured the actu-
al BW in all patients not dependent on HD (group
1) and all patients being treated by HD (groups 2
and 3) and recorded the actual BW in the electron-
ic health record.
Statistical Analysis
To compare the effect of patient characteristics
on the CT number of the popliteal arteries in the
three patient groups, we used the Steel-Dwass test
for multiple pairwise comparisons or chi-square
test. We used the Mann-Whitney U test or chi-
square test for comparisons of two patient groups.
Differences of p < 0.05 were considered to be
statistically significant. Statistical analyses were
performed using free statistical software (R, ver-
sion 3.0.2, The R Foundation).
AJR:208, May 2017 1129
Results
Comparisons of the CT Numbers for the
Three Groups
The median CT numbers were similar at
the five sites from the abdominal aorta to the
metatarsal artery for groups 1 and 3 (Fig. 3)
and were lower in group 2 than in groups 1
and 3. At the popliteal artery at the level of
the patella, the median CT number was 429
HU (range, 211–658 HU) in group 1, 373 HU
(range, 191–588 HU) in group 2, and 418 HU
(range, 278–638 HU) in group 3. There was
a statistically significant difference between
groups 2 and 3 (p < 0.01) and between groups
1 and 2 (p < 0.01) (Fig. 4). We observed the
same tendency with respect to the other mea-
surement sites.
Visualization Score of the Descending
Genicular Artery
A visualization score of 3 or 4 was as-
signed for visualization of the DGA on CTA
images of 77% of group 1, 59% of group 2,
and 72% of group 3 (Fig. 5). The score for
visualization of the DGA was significantly
lower in group 2 than in group 1 (p = 0.02)
and group 3 (p = 0.04). The Cohen kappa val-
ue for interobserver agreement was 0.59 for
groups 1 and 3 and 0.76 for group 2.
Difference in the Actual Body Weight and Dry
Body Weight
Figure 6 shows the difference in the ac-
tual BW and dry BW in groups 2 and 3. The
difference was significantly smaller in group
3 than group 2 (1.3 vs 2.0 kg, respectively;
p = 0.01).
Discussion
Our study shows that the median CT num-
ber on CTA scans was significantly lower in
patients undergoing HD less than 24 hours
after CTA (group 2) than in patients who un-
derwent HD less than 24 hours before CTA
(group 3) and in patients not treated by HD
(group 1). We also found that the DGA vi-
sualization score assigned to the images was
significantly lower for group 2 than for group
3 and group 1.
The difference between the actual BW and
dry BW was significantly smaller in group
3 than group 2. In general, the ECF volume
consists of two major subcompartments—
that is, the interstitial fluid volume and the
intravascular volume (blood plasma volume).
We therefore concluded that the ability to vi-
sualize small branch vessels on CTA scans
was degraded when patients with renal dys-
function were scanned before HD because of
the increase in their ECF volume.
In patients not dependent on HD, hyper-
volemia activates renal mechanisms to de-
crease expansion of the ECF volume. Be-
cause these mechanisms are compromised
in patients with impaired renal function,
there is excessive accumulation of ECF 2–3
days after HD [13]; this excess of ECF may
result in an increase in the dilution of con-
trast medium. HD returns the ECF volume to
the level found in patients without renal dys-
function [14]. Metry et al. [15] showed that
HD resulted in an increase in the hematocrit
level and a decrease in the intravascular vol-
ume. When the standard amount of contrast
medium is injected into a patient with a de-
creased intravascular volume and a higher
hematocrit level, the CT number can be ex-
pected to be higher. This increased CT num-
ber was observed in group 3 and may explain
why there was no significant difference be-
tween group 1 patients and group 3 patients
in the CT number of the popliteal artery and
the DGA visualization score.
The osmotic pressure of nonionic IV con-
trast material with an iodine concentration of
300 mg I/mL is 2–3 times greater than the
osmotic pressure of physiologic saline [16].
When contrast medium is administered IV
just after HD, it circulates in the body for a
maximum of 3 days [17]. Although the os-
motic load that the contrast medium impos-
es can theoretically elicit pulmonary edema
and anasarca [18], no complications were en-
countered in a study of HD patients who un-
derwent the IV delivery of iodinated contrast
medium [9]. Although the IV injection of io-
dinated contrast medium just after HD may
be acceptable, the administered dose should
be as low as possible for the acquisition of
diagnostic images without contrast medium–
induced toxicity.
Although we used a protocol with a fixed
contrast material dose in this study, some in-
stitutions use a protocol with a weight-based
contrast material dose [6, 19]. In general,
the contrast material injected in the vascu-
lar space is distributed rapidly to the ECF
volume (i.e., the volume of the plasma and
the interstitial fluid space) of parenchymal
organs. Consequently, the concentration of
contrast material in these organs is close-
ly related to the ECF volume. Boer [20] re-
ported that BW showed a relatively strong
positive linear correlation with ECF volume
(r = 0.75). Therefore, we think that determi-
nation of the contrast material dose based
 on the body habitus is physiologically val-
id. However, the BW of patients undergoing
HD changes in relation to the timing of HD.
Therefore, the contrast material dose for HD
patients should be determined by the BW
measured immediately before CTA.
Many patients with PAD present with
ischemic gangrene, ulceration, and pain at
­ ease and medial arterial calcification in patients
rest [22–23]. Endovascular treatment of their
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small vessels below the knee is an option and
requires the depiction of these vessels. The
risk of nephrogenic systemic fibrosis rules
out contrast-enhanced MR angiography [21,
23]; however, unenhanced images may be of
insufficient spatial resolution. Although CTA
is a good alternative, the amount of iodinated
contrast material used for CTA must be as low
as possible, especially in patients undergoing
HD. One method for reducing the contrast ma-
terial dose is to use low tube voltage scanning
techniques. As the enhancement of iodine is
boosted on low tube voltage scans [24–26], the
contrast dose can be reduced by approximately
20% [27, 28].
Our study has some limitations. First, be-
cause the actual BW of our patients was low-
er than that of North American and Europe-
an adults, the applicability of our findings
to populations with greater actual BW must
be examined. Second, our study was a non-
randomized retrospective study. We are now
planning a randomized prospective investi-
gation. Third, the volume of contrast medi-
um was not adjusted to the patient BW, and
a fixed volume of contrast material was de-
livered at a fixed injection rate. Last, in the
visual evaluation of the DGA, interobserv-
er agreement was moderate for groups 1
and 3 (Cohen κ value, 0.59). Consequently,
the consensus reading may have masked the
true difference in the visualization scores be-
tween groups 1 and 3.
In conclusion, as the time interval between
HD and CTA increases, arterial enhance-
ment decreases likely because of a significant
increase in BW. CTA should be ideally per-
formed within 24 hours after HD. When this
timing is not possible, strategies to avoid im-
age quality degradation should be in place.
References
1. Newman AB, Siscovick DS, Manolio TA, et al.
Ankle-arm index as a marker of atherosclerosis in
the Cardiovascular Health Study: Cardiovascular
Heart Study (CHS) Collaborative Research
Group. Circulation 1993; 88:837–845
2. Eggers PW, Gohdes D, Pugh J. Nontraumatic low-
er extremity amputations in the Medicare end-
stage renal disease population. Kidney Int 1999;
1130 AJR:208, May 2017
56:1524–1533
Masuda et al.
3. O’Hare AM, Hsu CY, Bacchetti P, Johansen KL.
Peripheral vascular disease risk factors among pa-
tients undergoing hemodialysis. J Am Soc Nephrol
2002; 13:497–503
4. Leskinen Y, Salenius JP, Lehtimaki T, Huhtala H,
Saha H. The prevalence of peripheral arterial dis-
with chronic renal failure: requirements for diag-
nostics. Am J Kidney Dis 2002; 40:472–479
5. Beto JA, Bansal VK, Ing TS, Daugirdas JT. Varia-
tion in blood sample collection for determination
of hemodialysis adequacy: Council on Renal Nu-
trition National Research Question Collaborative
Study Group. Am J Kidney Dis 1998; 31:135–141
6. Fleischmann D, Hallett RL, Rubin GD. CT angi-
ography of peripheral arterial disease. J Vasc
I­nterv Radiol 2006; 17:3–26
7. Lell M, Tomandl BF, Anders K, Baum U, Nkenke
E. Computed tomography angiography versus
digital subtraction angiography in vascular map-
ping for planning of microsurgical reconstruction
of the mandible. Eur Radiol 2005; 15:1514–1520
8. Younathan CM, Kaude JV, Cook MD, Shaw GS,
Peterson JC. Dialysis is not indicated immediately
after administration of nonionic contrast agents in
patients with end-stage renal disease treated by
maintenance dialysis. AJR 1994; 163:969–971
9. Fowkes FG, Rudan D, Rudan I, et al. Comparison
of global estimates of prevalence and risk factors
for peripheral artery disease in 2000 and 2010: a
systematic review and analysis. Lancet 2013;
382:1329–1340
10. Nette RW, Krepel HP, van den Meiracker AH,
Weimar W, Zietse R. Specific effect of the infusion
of glucose on blood volume during haemodialysis.
Nephrol Dial Transplant 2002; 17:1275–1280
12. Nakai S, Iseki K, Itami N, et al. An overview of
regular dialysis treatment in Japan as of Decem-
ber 31, 2009. Ther Apher Dial 2012; 16:11–53
12. Thomson GE, Waterhouse K, McDonald HP Jr,
Friedman EA. Hemodialysis for chronic renal
failure: clinical observations. Arch Intern Med
1967; 120:153–167
13. Katayama T, Sato T, Minato K. Estimation of ex-
tracellular volume by simultaneous instrumenta-
tion of bioimpedance and plasma colloid osmotic
pressure. Trans Japan Soc Med Biol Engineering
2005; 43:717–723
14. Jaeger JQ, Mehta RL. Assessment of dry weight in
hemodialysis: an overview. J Am Soc Nephrol
1999; 10:392–403
15. Metry G, Adhikarla R, Schneditz D, Ronco C,
Levin NW. Effect of changes in the intravascular
volume during hemodialysis on blood viscoelas-
ticity. Indian J Nephrol 2011; 21:95–100
16. Gallotti A, Uggeri F, Favilla A, Cabrini M, de
Haën C. The chemistry of iomeprol and physico-
chemical properties of its aqueous solutions and
pharmaceutical formulations. Eur J Radiol 1994;
18(suppl 1):S1–S12
17. Lindsay RM, Suri RS, Moist LM, et al. Interna-
tional Quotidian Dialysis Registry: annual report
2010. Hemodial Int 2011; 15:15–22
18. ACR Committee on Drugs and Contrast Media. ACR
manual on contrast media, version 10.1, 2015.
­Reston, VA: American College of Radiology, 2015:40
19. Shimizu K, Utsunomiya D, Nakaura T, et al. Uni-
form vascular enhancement of lower-extremity
artery on CT angiography using test-injection
monitoring at the central level of the scan range: a
simulation flow phantom study with clinical cor-
relation. Acad Radiol 2010; 17:1153–1157
20. Boer P. Estimated lean body mass as an index for
normalization of body fluid volumes in humans.
Am J Physiol 1984; 247:F632–F636
21. Schwarten DE, Cutcliff WB. Arterial occlusive
disease below the knee: treatment with percutane-
ous transluminal angioplasty performed with low-
profile catheters and steerable guide wires.
­Radiology 1988; 169:71–74
22. Liistro F, Porto I, Angioli P, et al. Drug-eluting
balloon in peripheral intervention for below the
knee angioplasty evaluation (DEBATE-BTK): a
randomized trial in diabetic patients with critical
limb ischemia. Circulation 2013; 128:615–621
23. Keeling AN, Khalidi K, Leong S, et al. Below
knee angioplasty in elderly patients: predictors of
major adverse clinical outcomes. Eur J Radiol
2011; 77:483–489
24. Higashigaito K, Schmid T, Puippe G, et al. CT an-
giography of the aorta: prospective evaluation of
individualized low-volume contrast media proto-
cols. Radiology 2016; 280:960–968
25. Seyal AR, Arslanoglu A, Abboud SF, Sahin A,
Horowitz JM, Yaghmai V. CT of the abdomen
with reduced tube voltage in adults: a practical ap-
proach. RadioGraphics 2015; 35:1922–1939
26. Kim JW, Choo KS, Jeon UB, et al. Diagnostic per-
formance and radiation dose of lower extremity CT
angiography using a 128-slice dual source CT at 80
kVp and high pitch. Acta Radiol 2016; 57:822–828
27. Nakaura T, Awai K, Maruyama N, et al. Abdomi-
nal dynamic CT in patients with renal dysfunc-
tion: contrast agent dose reduction with low tube
voltage and high tube current-time product set-
tings at 256-detector row CT. Radiology 2011;
261:467–476
28. Nakaura T, Nagayama Y, Kidoh M, et al. Low
contrast dose protocol involving a 100 kVp tube
voltage for hypervascular hepatocellular carcino-
ma in patients with renal dysfunction. Jpn J
­Radiol 2015; 33:566–576
29. Masuda T, Funama Y, Nakaura T, et al. Delivering
the saline chaser via a spiral flow-generating tube
improves arterial enhancement for computed to-
mography angiography of the lower extremities.
J Comput Assist Tomogr 2015; 39:962–968
(Figures start on next page)
 Fig. 1—Maximum-intensity-projection image (left)
Lower Extremity CTA of Patients With Suspectedand
PAD
axial CT images (right) show measurement sites
in 65-year-old man. Level “a” is abdominal aorta
(arrow) at third lumbar vertebral level. Level “b” is
external iliac arteries (arrows) at hip joint level. Level
“c” is femoral arteries (arrows) at middle of femur.
Level “d” is popliteal arteries (arrows) at level of
patella. Level “e” is dorsalis pedis arteries (arrows) at
lateral malleolus level.
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Fig. 2—Reviewers used 4-point scale to grade

visualization of descending genicular artery (DGA) on
lower extremity CT angiograms. CT angiograms show
examples of each score.
A, 72-year-old man. Score of 4 was assigned because
main trunk of DGA is visible and almost entire portion
of its first branches (arrows) was observed.
B, 68-year-old woman. Score of 3 was assigned
because entire DGA is visible but its first branches
are ambiguous.
A B (Fig. 2 continues on next page)

AJR:208, May 2017 1131

 Masuda et al.

Fig. 2 (continued)—Reviewers used 4-point scale

to grade visualization of descending genicular
artery (DGA) on lower extremity CT angiograms. CT
angiograms show examples of each score.
C, 63-year-old man. Score of 2 was assigned because
part of DGA is visible.
D, 78-year-old woman. Score of 1 was assigned
because DGA is not visible.
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C D

600 Group 1
Group 2
CT Number at Lower Extremity CTA (HU)

Group 3

500 437 429

415 421 418
402
391 396 386
366 373
400 356

300 255 240

217

200
Fig. 3—Bar graph shows intravascular contrast enhancement in Hounsfield units
at lower extremity CT angiography (CTA) in patients who were not dependent on
100 hemodialysis (HD) (group 1), patients who were dependent on HD and underwent
HD less than 24 hours after CTA (group 2), and patients who were dependent on
HD and underwent HD less than 24 hours before CTA (group 3). Data are presented
as medians ± 1 standard error (whiskers). Level a is abdominal aorta at third
0
Level a Level b Level c Level d Level e lumbar vertebral level; Level b is external iliac arteries at hip joint level; Level c is
Measurement Portion femoral arteries at middle of femur; Level d is popliteal arteries at level of patella;
and Level e is dorsalis pedis arteries at lateral malleolus level.

700

600
at the Level of the Patella (HU)
CT Number of Popliteal Artery

500

400

300 Fig. 4—Box-and-whisker plot shows contrast enhancement in Hounsfield units

of popliteal artery at level of patella in patients who were not dependent on
hemodialysis (HD) (group 1), patients who were dependent on HD and underwent
200
HD less than 24 hours after CT angiography (CTA) (group 2), and patients who
p < 0.01 p < 0.01 were dependent on HD and underwent HD less than 24 hours before CTA (group
100
3). Median CT number (lines in middle of boxes) was significantly lower in group 2
p < 0.98 patients who underwent HD less than 24 hours after CTA (373 HU) than in group 3
patients who underwent HD less than 24 hours before CTA (418 HU) (p < 0.01) and
0 in group 1 patients who were not dependent on HD (429 HU) (p < 0.01). Upper and
Group 1 Group 2 Group 3 lower lines of boxes show 75th and 25th percentiles; whiskers who maximum and
minimum values.

1132 AJR:208, May 2017

 Lower Extremity CTA of Patients With Suspected PAD

Fig. 5—Visualization scores assigned to descending genicular artery (DGA) in

100
Score = 4 patients who were not dependent on hemodialysis (HD) (group 1), patients who
Score = 3 were dependent on HD and underwent HD less than 24 hours after CT angiography
Score = 4, Score = 2 (CTA) (group 2), and patients who were dependent on HD and underwent HD less
Percentage of Patients With DGA

80 30% Score = 1 than 24 hours before CTA (group 3). Scores were significantly lower in group 2
Score = 4, Score = 4,
50% 50% patients than in group 1 patients (p = 0.02) and group 3 patients (p = 0.04).
Visualization Score

60 Score = 3,
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29%

40 Score = 3, Score = 3,
27% 22%
Score = 2,
20 34%
Score = 2, Score = 2,
22% 27% Score = 1,
1%
0
Group 1 Group 2 Group 3
Score = 1,
7%

8
Difference Between Actual Body Weight

6
and Dry Body Weight (kg)

Fig. 6—Comparison of actual body weight (BW) and dry BW in patients who
0
underwent hemodialysis (HD) less than 24 hours after CT angiography (CTA)
p = 0.02
(group 2) and patients who underwent HD less than 24 hours before CTA (group
3). Difference was significantly greater in group 2 than in group 3 (2.0 vs 1.3 kg,
–2 respectively; p = 0.01). Middle lines in boxes show medians; upper and lower lines
Group 2 Group 3 of boxes show 75th and 25th percentiles; whiskers show maximum and minimum
values; circles show outliers.

F O R YO U R I N F O R M AT I O N
A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.

AJR:208, May 2017 1133