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1 Department of Radiology, University of British Columbia, UBC Hospital Site,
2211 Wesbrook Mall, Vancouver, B. C., V6T 2B5, Canada.
2 Department of Vascular Surgery, University of British Columbia, Vancouver, B.
C., V6T 2B5, Canada.
Received May 16, 2002;
accepted after revision September 17, 2002.
Address correspondence to M. L. Martin.
Abstract
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SUBJECTS AND METHODS. Forty-one patients with ischemic legs underwent both MDCT angiography and DSA of the aortoiliac system and the legs. The arterial supply of the legs was divided into 35 segments. Three independent observers rated each segment according to the maximal degree of arterial stenosis. Consensus interpretation was used to calculate the sensitivity and specificity of MDCT angiography in showing arterial occlusions and stenoses of at least 75%. Intertechnique agreement was measured for each anatomic segment, and interobserver agreement was calculated for both techniques. Agreement was quantified using the kappa statistic.
RESULTS. The sensitivity and specificity of MDCT angiography for
depicting arterial occlusions and stenoses of at least 75% were 88.6% and
97.7%, and 92.2% and 96.8%, respectively. Substantial intertechnique agreement
(
> 0.4) was present in 102 (97.1%) of 105 arterial segments.
Substantial interobserver agreement was present in 104 (99.0%) of 105
comparisons for both MDCT angiography and DSA with an average kappa value of
0.84 for CT and 0.78 for DSA. MDCT angiography showed more patent segments
than DSA (1192 vs 1091). All nine segments seen on DSA and not seen on MDCT
angiography were in the calves. Of 110 segments seen on MDCT angiography and
not seen on DSA, 100 (90.9%) were in the calves.
CONCLUSION. MDCT angiography was accurate in showing arterial atheroocclusive disease with reliability similar to DSA. MDCT angiography showed more vascular segments than DSA, particularly within calf vessels.
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MDCT angiography of the entire arterial supply of the legs from the suprarenal aorta to the ankles in a single helical acquisition using an MDCT scanner was recently described [10]. Those researchers focused primarily on showing the ability of MDCT angiography to acquire images with sufficient arterial opacification and only briefly touched on the accuracy of this modality. To our knowledge, no research has been published that confirms the accuracy and reliability of MDCT angiography when performed over such a large anatomic range. The purpose of our study was to determine the accuracy and reliability of MDCT angiography of the lower extremities in the evaluation of symptomatic atheroocclusive disease.
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Of the 50 patients who fit the study criteria, 42 (84%) agreed to participate. All patients were enrolled prospectively and signed a written consent before undergoing imaging. One patient had an interstitial contrast injection during attempted MDCT angiography and asked to be withdrawn from the study. The remaining 41 patients (28 men and 13 women; age range, 45–84 years; mean age, 67.4 years) underwent both MDCT angiography and DSA. CT angiography was performed before DSA in 33 patients and after in eight patients. The average time between examinations was 13.3 days (range, 5–76 days). Patients were being investigated for category 1 (mild claudication, n = 7), category 2 (moderate claudication, n = 10), category 3 (severe claudication, n = 18), category 4 (ischemic rest pain, n = 3), or category 5 (minor tissue loss, n = 6) lower limb ischemia [11]. Nine patients had undergone arterial bypasses (aortobifemoral bypass [n = 2], unilateral infrainguinal bypass [n = 2], or bilateral infrainguinal bypass [n = 5]). Four patients had undergone previous percutaneous angioplasty (n = 1) or stenting (n = 3).
MDCT Angiography
MDCT angiography was performed on an AsteionVR four-channel MDCT scanner
(Toshiba, Tokyo, Japan). Patients were in the supine position on the CT table
with their legs held together and their feet held in plantar flexion. No
strapping or tape was placed on the patient's legs. An anteroposterior scout
image was obtained from the dome of the diaphragm to the toes. While the
patient held both arms above the head, ioversol iodinated contrast material
(Optiray 320; Mallinckrodt Canada, Pointe-Claire, Canada) was injected at 4
mL/sec through a 20-to 22-gauge IV catheter into the patient's antecubital
fossa or forearm for a total volume of 120 mL. The abdominal aorta at the
level of the celiac artery was observed with real-time CT fluoroscopy, and
helical acquisition was triggered automatically when the density of the
abdominal aorta increased 120 H above the baseline.
A single helical acquisition was obtained from the origin of the celiac artery to the toes using a standardized protocol with the following scanning parameters: nominal section thickness, 5.0 mm; gantry rotation period, 0.75 sec; table speed, 27.5 mm per rotation (5.5 pitch); 230 mAs; 120 kV; linear interpolation algorithm, 180°; reconstruction interval, 2.5 mm; and field of view, 500 mm. Patients were asked to breathe gently during image acquisition. Image acquisition from triggering of the helical acquisition to completion averaged approximately 35 sec. The entire examination took 10–15 min.
MDCT angiograms were processed on a threedimensional workstation (Vitrea; Vital Images, Plymouth, MN) by one of the investigators. Anteroposterior and oblique views of the aorta and iliac vessels were acquired using three-dimensional volume rendering. Infrainguinal bony structures were manually subtracted by drawing several region-of-interest areas around the bones, connecting the region-of-interest with a surfacing tool, and subtracting bony structures from the displayed images. Images of the infrainguinal leg runoff with both volume-rendered and maximum-intensity-projection reconstructions were then acquired. Both source and reformatted images were sent to a PACS (picture archiving and communication system) workstation (Impax DS 3000, release 4.1; AGFA Group, Mortsel, Belgium).
DSA
Conventional angiography was performed with a digital subtraction technique
(Advantx AFM/DXC; General Electric Medical Systems, Milwaukee, WI).
Angiography was performed using a right common femoral artery approach
(n = 25), a left common femoral artery approach (n = 15), or
a right brachial artery approach (n = 1). Undiluted ioversol
iodinated contrast material was used. All patients were evaluated with
posteroanterior aortography, bilateral oblique iliac angiography, and
individual stepping runs of both legs. For leg runs, the diagnostic catheter
was positioned in the external iliac artery when possible. In cases of common
iliac artery occlusion, contrast medium was injected into the distal aorta to
image the ipsilateral leg. Blood pressure cuffs were temporarily inflated
around the ankles and were deflated at the time of the stepping runs to elicit
reactive hyperemia of the calves. The performance of angiography of both legs
separately is favored in our institution because it negates the effects of
differential rates of arterial runoff between legs and simplifies image
processing if patient movement occurs. Reactive hyperemia, in our experience,
improves visualization of calf vasculature and is used routinely in our
practice. Supplementary DSA runs of the calves were performed at the
discretion of the angiographer. The average contrast dose was 175 mL (range,
130–260 mL). Percutaneous angioplasty or stenting was performed at the
discretion of the angiographer at the time of DSA.
Data Collection
Three radiologists independently evaluated both the DSA and the MDCT
angiography studies over a 2-month period in a randomized order. Two of these
radiologists were fellowship-trained interventional radiologists with
cross-sectional imaging experience, and the third was a cross-sectional imager
with extensive experience in diagnostic angiography. The observers were
unaware of results from the other modality and of the interpretation of other
reviewers. Hard-copy images were used for DSA interpretation, and MDCT studies
were interpreted on a PACS workstation. Patient information on DSA studies was
obscured with opaque tape. Patient information could not be blocked from the
MDCT studies.
The arterial supply was divided into 35 anatomic segments: both legs were divided into the common iliac artery; the external iliac artery; the common femoral artery; the proximal and distal superficial femoral and popliteal arteries; the tibioperoneal trunk; and the proximal, mid, and distal thirds of the calf vessels. The infrarenal aorta was considered a single segment. Arterial bypass grafts were not evaluated. Hard-copy DSA images were marked with a grease pencil at the junctures between anatomic segments. The source images from the MDCT studies were marked using arrows at the anatomic division sites. The anatomic segments were matched on the DSA and MDCT images to ensure reliable correlation. Source images were used for MDCT interpretation, with supplemental use of reformatted images when necessary. The anatomic segments were marked by one of the investigators 1 month before interpretation.
Each vessel segment was assigned a grade for maximal disease extent by each observer using a 5-point ordinal scale: 0 = 0–24% stenosis, 1 = 25–49% stenosis, 2 = 50–74% stenosis, 3 = 75–99% stenosis, and 4 = occlusion. For all arterial segments, even those with aneurysmal dilatation, the degree of stenosis was measured by dividing the minimal vessel luminal diameter within the segment by the maximal observed luminal diameter. Electronic calipers were used for MDCT measurements, and mechanical calipers, for hard-copy DSA images. Some degree of subjectivity was allowed in the assessment of both techniques because caliper measurement of small runoff vessels was often difficult. In cases in which no opacification was present in all or part of an arterial segment, the segment was rated as either occluded or not seen. Vessels were designated as not seen when, in the observer's opinion, the arterial segment was inadequately visualized as a result of either suboptimal bolus timing or patient motion. Interpretations were recorded on a study worksheet. No interaction between investigators was allowed during the initial evaluation of techniques. After all studies were evaluated, the results were reviewed to identify discrepant interpretations. All discrepant results within each modality were resolved by consensus between reviewers, who remained unaware of the results of the other modality.
Statistical Analysis
Statistical analysis was performed using S-plus 6.0 software (Insightful,
Seattle, WA). Consensus interpretations were used to calculate the sensitivity
and specificity, with 95% confidence intervals (CIs) for MDCT angiography in
revealing stenoses of at least 75% and arterial occlusions using DSA as the
gold standard. Intertechnique agreement was determined for each anatomic
segment by the calculation of the kappa statistic with quadratic weighting.
The intertechnique kappa statistic was computed three times for each segment
on the basis of the ordinal scale values supplied by each of the three
observers. The kappa coefficient is a measurement of concordance for ordinal
data with a correction for chance agreement, with weighting of results to
distinguish varying degrees of disagreement between observers
[12]. Interobserver agreement
for each technique was determined for each anatomic segment by calculating
kappa values for all two-way combinations of observers. The average kappa
values for interobserver agreement were calculated for both techniques. Vessel
segments graded as not shown on one or both techniques were not used in the
kappa calculation.
Consensus interpretations were reviewed to determine the incidence and cause of significant discrepant results. Results differing by more than one category of disease severity or cases in which one modality showed a patent segment and the other an occlusion were considered discrepant results. Cases of nonvisualized segments were reviewed to determine both the anatomic location of segments and the corresponding interpretation of the findings of the other modality.
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Consensus results are summarized in Table 1. Of the 1425 arterial segments (10 segments were not included in one patient with an amputation below the knee), 105 (7.4%) were graded as not seen on DSA and 22 (1.5%) as not seen on MDCT angiography. These segments were not used for calculation of sensitivity and specificity or for intertechnique and interobserver agreement. Using DSA as the gold standard, we found that the sensitivity and specificity of MDCT angiography for revealing arterial occlusions were 88.6% (95% CI, 83.6–92.3%) and 97.7% (CI, 96.5–98.4%). For arterial stenoses of greater than 75%, sensitivity and specificity were 92.2% (CI, 80.0–95.0%) and 96.8% (CI, 95.5–97.7%).
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Kappa values for intertechnique agreement were 0.8–1.0 in 38 (36%) of 105 segments, 0.6–0.79 in 44 (42%) of 105, 0.4–0.59 in 20 (19%) of 105, 0.2–0.39 in one (1.0%) of 105, and 0–0.19 in two (1.9%) of 105. Eleven of the 12 lowest correlation scores occurred in the peroneal artery segments. Kappa values for interobserver agreement for DSA were 0.8–1.0 in 55 (52%) of 105 comparisons, 0.6–0.79 in 39 (37%) of 105, 0.4–0.59 in 10 (9.5%) of 105, and 0.2–0.39 in one (1%) of 105. For MDCT angiography, interobserver kappa values were 0.8–1.0 in 84 (80%) of 105 comparisons, 0.6–0.79 in 18 (17%) of 105, 0.4–0.59 in two (1.9%) of 105, and 0.2–0.39 in one (1%) of 105. For both techniques, the lowest correlation scores were in the mid peroneal artery segments.
Discrepant results were present in 51 (3.6%) of 1425 comparisons involving 24 (58.5%) of 41 subjects. Of these, 28 involved segments were rated as occluded on MDCT angiography but patent on DSA (n = 2) or occluded on DSA but patent on MDCT (n = 26). The segments interpreted as occluded on MDCT angiography but patent on DSA were located in the mid segment of the posterior tibial artery and in the distal anterior tibial artery. Of the 26 segments believed to be patent on MDCT angiography but occluded on DSA, 21 (80.8%) were in segments below the knee and five (19.2%) were in segments above the knee distal to long-segment arterial occlusions (Fig. 2A, 2B, 2C, 2D, 2E).
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Interpretations differing by more than one category of stenosis in patent segments were present in 23 (1.6%) of 1425 comparisons. Thirteen of these discrepancies were cases in which MDCT angiography yielded a higher estimate of disease, of which six involved segments above the knee and seven, below the knee. Ten discrepancies were cases in which DSA depicted a higher degree of stenosis, nine of which involved segments below the knee and one of which involved the external iliac artery (Fig. 1A, 1B).
Twenty-two (1.5%) of the 1425 vessel segments were rated as not seen on MDCT angiography. All of the segments were located in the distal third of the calves involving the anterior tibial (n = 12), the peroneal (n = 8), or the posterior tibial (n = 2) artery. Fourteen (63.6%) of these segments were rated as not seen, seven (31.8%) as patent, and one (4.5%) as occluded on the corresponding DSA study. On DSA, 105 (7.4%) of the 1425 vessel segments were rated as not seen. These segments were located in the distal third of calf vessels in 46 (43.8%), mid calf vessels in 31 (29.5%), and proximal calf vessels in 15 (14.3%), and between the groin and tibioperoneal trunk bifurcation in 13 (12.4%). On MDCT angiography, 14 (13.3%) of these segments were not seen, 84 (80%) were patent, and seven (6.7%) were occluded. In total, MDCT angiography showed 1192 segments to be patent, whereas DSA showed 1091.
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There has been limited evaluation of the accuracy of MDCT angiography in the diagnosis of atheroocclusive disease of the infrainguinal arteries. In a technical note, Lawrence et al. [5] described the use of single-detector CT angiography to show the lower extremity arterial system from the groin to the mid calf using two separate helical acquisitions with a 5-mm collimation and a pitch of 1.0. A prospective study by Rieker et al. [7] evaluated CT angiography of the leg from the groin to the mid calf in a single helical acquisition with a single-detector scanner using a 5-mm collimation and a pitch of 2.0. Sensitivities of 94–100% for arterial occlusions and 67–88% for stenoses of 75–99% were reported, with specificities ranging from 98% to 100% for occlusions and from 94% to 100% for severe stenoses. Although the results of this study were promising, the scan coverage was limited to 70 cm, and therefore the aortoiliac vessels and the distal calves were not evaluated. In addition, the wide effective slice thickness likely contributed to errors in assessment of short stenoses. Rubin et al. [10] recently described the imaging of the entire arterial supply of the lower extremities in a single helical acquisition using a 3.2-mm effective slice thickness and 1.6-mm reconstruction intervals. This study focused on the ability of MDCT angiography to reveal all arterial segments with sufficient opacification and without venous contamination. Of 24 subjects, 18 also underwent conventional angiography. Both techniques were reviewed in this subgroup of patients, and the arterial segments were rated for the degree of stenosis. A 100% concordance of revealing stenosis at direct comparison in segments shown on both MDCT angiography and conventional angiography was reported. This assessment did not appear to have been performed in a blinded prospective manner, and intertechnique and intermodality discrepancies were settled by consensus.
Our study reveals that MDCT angiography has excellent specificity in showing severe (>75%) stenoses (Fig. 3A, 3B) and arterial occlusions (96.8% and 97.7%, respectively), with good sensitivity (92.2% and 88.6%, respectively). The lower sensitivity largely resulted from 26 arterial segments being interpreted as patent on MDCT and occluded on DSA. Although some of these segments may represent misinterpretations by CT as a result of severe diffuse calcification, a number of these segments were undoubtedly patent but not seen on DSA because of differential rates of filling within calf vessels, insufficient arterial opacification distal to occlusions, or severe motion artifact. The inability of DSA to show calf vessels in patients with proximal occlusions is well documented [13], and we speculate that MDCT angiography may allow better visualization of calf vessels in these patients because a systemic contrast bolus is used and because image quality is largely unaffected by patient motion.
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The degree of agreement between a new test and an established test is related to diagnostic accuracy. In our study, there was substantial agreement between MDCT angiography and DSA for three independent observers in nearly every arterial segment. The lowest kappa scores occurred in the calf vessel segments, likely resulting from the difficulty of accurately measuring the very small vessels and because of the inability of DSA to show several patent vessels seen on MDCT angiography. Reliability, also referred to as reproducibility, refers to the extent to which repeated measurements on the same subject yield the same results [14]. Reliability is an important determinant of the clinical usefulness of a test because even an accurate test is of limited use if the results are widely scattered about the true value of the condition being measured. In addition, unreliability can result in the underestimation of the accuracy of a new modality [15]. The high level of interobserver agreement indicates that MDCT angiography reveals disease in a manner that is reproducibly interpreted by different observers.
Discrepant results were present in at least one vessel segment in most (58.5%) of the patients in our study, raising the possibility that MDCT angiography could alter treatment planning in a large number of patients. However, in only one instance did a discrepancy result in alterations in decision making regarding percutaneous treatment (Fig. 1A, 1B). We did not determine whether the other discrepancies changed surgical decisions. However, a large number of the discrepancies represented cases in which vessel segments were visualized on MDCT but not on DSA, and it seems likely that in at least some cases, MDCT revealed potential recipient sites for surgical bypass that were not seen on DSA. Further studies will be necessary to determine whether the different information provided by MDCT angiography adversely or positively affects clinical decision making in the treatment of peripheral vascular disease.
We recognize that our study has several limitations. First, both imaging techniques were performed in a manner that may have falsely underestimated their ability to depict disease. MDCT studies were performed with a relatively wide effective slice thickness and, as a result, z-axis resolution was decreased and limited our ability to identify short focal stenoses. Since the completion of this study, we have changed our scanning parameters to using 3-mm slice thickness. With the release of 8- and 16-detector scanners, lower extremity MDCT angiography can now be performed with submillimeter collimation, essentially eliminating problems with z-axis resolution. Our scanning protocol used excessive table speed, and several distal calf vessels were insufficiently opacified as a result. Slowing table speed by using a narrower slice thickness has significantly reduced this problem, in our experience. DSA was performed in a manner that likely resulted in an underestimation of patent calf vessels. More patent calf vessels may have been seen had dedicated calf angiography been performed, but to limit contrast dose, additional runs were performed only if it was believed that insufficient information had been obtained with the stepping run. These factors may have decreased our ability to determine the accuracy of MDCT angiography in an idealized setting. However, the difficulties encountered with both techniques are a reflection of their limitations in clinical use, and this allowed the comparison of the two techniques in a clinically realistic and reproducible scenario.
Accuracy, the degree to which the results of a test reflects the true state of disease, is measured by comparing the results of a new test with an established gold standard and is typically reported in terms of sensitivity and specificity. The determination of these values for angiographic techniques is often difficult because the ideal gold standard of reference with which to compare a new modality may differ depending on the extent and pattern of disease. Whereas DSA is usually thought to provide the most consistent, reproducible results of currently available angiographic techniques, other techniques such as intraoperative angiography or time-of-flight MR angiography have been shown to be more accurate in visualizing distal patent vessels in cases of severe proximal occlusive disease [13]. The use of an imperfect modality as a reference standard in the assessment of a new modality has important experimental implications because it can lead to substantial underestimation of the accuracy of the new test [16]. Calculation of the true sensitivity and sensitivity of MDCT angiography in depicting arterial occlusions and stenoses will have to be established through the comparison of CT with multiple angiographic techniques, including MR angiography, intraoperative angiography, and surgical findings.
An important consideration not addressed in our study is that of radiation dose. Unfortunately, neither our MDCT scanner nor our DSA unit was equipped with radiation dosimeters, and we are unable to comment on the relative radiation exposure using these techniques. Rubin et al. [10] calculated radiation doses in their study and found that the whole-body dose of MDCT angiography was 3.9 times lower than that with DSA. Clearly, radiation doses will vary greatly depending on the technique used and the patient body habitus. As MDCT angiography develops, techniques should be refined to minimize patient dose without compromising image quality. However, even in early use, it appears MDCT angiography may offer an advantage over DSA with regard to radiation dose.
Our results indicate that MDCT angiography is a reliable method of investigating patients with lower extremity ischemia and provides a similar estimate of the extent of atheroocclusive disease as that of stepping table DSA. MDCT may be more sensitive than DSA in identifying patent vessels distal to severe occlusions, but this difference in sensitivity will have to be evaluated by comparing these two techniques with a more sensitive reference standard such as MR angiography or intraoperative angiography. Validation of MDCT angiography will require further investigation regarding its effect on clinical decision making, patient outcomes, and cost-effectiveness. However, MDCT angiography of the lower extremities appears to be a promising new diagnostic test that will likely have an important role in the investigation of peripheral vascular disease.
Acknowledgments
We thank Nestor Muller for his assistance in the preparation of this
article.
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T. Schertler, S. Wildermuth, H. Alkadhi, M. Kruppa, B. Marincek, and T. Boehm Sixteen-Detector Row CT Angiography for Lower-Leg Arterial Occlusive Disease: Analysis of Section Width Radiology, November 1, 2005; 237(2): 649 - 656. [Abstract] [Full Text] [PDF]
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M. C. J. M. Kock, M. E. A. P. M. Adriaensen, P. M. T. Pattynama, M. R. H. M. van Sambeek, H. van Urk, T. Stijnen, and M. G. M. Hunink DSA versus Multi-Detector Row CT Angiography in Peripheral Arterial Disease: Randomized Controlled Trial Radiology, November 1, 2005; 237(2): 727 - 737. [Abstract] [Full Text] [PDF]
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R. Ouwendijk, M. C. J. M. Kock, K. Visser, P. M. T. Pattynama, M. W. de Haan, and M. G. M. Hunink Interobserver Agreement for the Interpretation of Contrast-Enhanced 3D MR Angiography and MDCT Angiography in Peripheral Arterial Disease Am. J. Roentgenol., November 1, 2005; 185(5): 1261 - 1267. [Abstract] [Full Text] [PDF]
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 M. M. Miller-Thomas, O. C. West, and A. M. Cohen Diagnosing Traumatic Arterial Injury in the Extremities with CT Angiography: Pearls and Pitfalls RadioGraphics, October 1, 2005; 25(suppl_1): S133 - S142. [Abstract] [Full Text] [PDF]
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H. Ota, K. Takase, H. Rikimaru, M. Tsuboi, T. Yamada, A. Sato, S. Higano, T. Ishibashi, and S. Takahashi Quantitative Vascular Measurements in Arterial Occlusive Disease RadioGraphics, September 1, 2005; 25(5): 1141 - 1158. [Abstract] [Full Text] [PDF]
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D. Fleischmann and G. D. Rubin Quantification of Intravenously Administered Contrast Medium Transit through the Peripheral Arteries: Implications for CT Angiography Radiology, September 1, 2005; 236(3): 1076 - 1082. [Abstract] [Full Text] [PDF]
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J. K. Willmann, B. Baumert, T. Schertler, S. Wildermuth, T. Pfammatter, F. R. Verdun, B. Seifert, B. Marincek, and T. Bohm Aortoiliac and Lower Extremity Arteries Assessed with 16-Detector Row CT Angiography: Prospective Comparison with Digital Subtraction Angiography Radiology, September 1, 2005; 236(3): 1083 - 1093. [Abstract] [Full Text] [PDF]
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R. Ouwendijk, M. de Vries, P. M. T. Pattynama, M. R. H. M. van Sambeek, M. W. de Haan, T. Stijnen, J. M. A. van Engelshoven, and M. G. M. Hunink Imaging Peripheral Arterial Disease: A Randomized Controlled Trial Comparing Contrast-enhanced MR Angiography and Multi-Detector Row CT Angiography Radiology, September 1, 2005; 236(3): 1094 - 1103. [Abstract] [Full Text] [PDF]
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P.-A. Poletti, A. Rosset, D. Didier, P. Bachmann, F. R. Verdun, O. Rutschmann, J.-P. Vallee, F. Terrier, and G. Khatchatourov Subtraction CT Angiography of the Lower Limbs: A New Technique for the Evaluation of Acute Arterial Occlusion Am. J. Roentgenol., November 1, 2004; 183(5): 1445 - 1448. [Full Text] [PDF]
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M. Karcaaltincaba, D. Akata, U. Aydingoz, G. Leblebicioglu, D. Akinci, B. Cil, A. Besim, and O. Akhan Three-Dimensional MDCT Angiography of the Extremities: Clinical Applications with Emphasis on Musculoskeletal Uses Am. J. Roentgenol., July 1, 2004; 183(1): 113 - 117. [Full Text] [PDF]
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M. Karcaaltincaba, D. Akata, G. Leblebicioglu, M. Haliloglu, D. Akinci, F. Balkanci, and A. Besim MDCT Angiography of the Extremities in Pediatric Patients: Initial Experience Am. J. Roentgenol., July 1, 2004; 183(1): 189 - 192. [Abstract] [Full Text] [PDF]
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H. Ota, K. Takase, K. Igarashi, Y. Chiba, K. Haga, H. Saito, and S. Takahashi MDCT Compared with Digital Subtraction Angiography for Assessment of Lower Extremity Arterial Occlusive Disease: Importance of Reviewing Cross-Sectional Images Am. J. Roentgenol., January 1, 2004; 182(1): 201 - 209. [Abstract] [Full Text] [PDF]
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