Optimizing Pulmonary Embolism Computed Tomography in the Age of Individualized Medicine A Prospective Clinical Study

Purpose: The aim of the study was to simultaneously optimize contrast media (CM) injection and scan parameters for the individual patient during computed tomography pulmonary angiography (CTPA). Methods: In this study (NCT02611115), 235 consecutive patients suspected of having pulmonary embolism were prospectively enrolled. Automated kV selection software on a third-generation multidetector computed tomography adapted tube voltage to the individual patient, based on scout scans. The contrast injection protocol was adapted to both patient body weight and kV-setting selection via a predefined formula, based on previous research. Injection data were collected from a contrast media and radiation dose monitoring software. Attenuation was measured in Hounsfield units (HU) in the pulmonary trunk (PT); attenuation values 200 HU or greater were considered diagnostic. Subjective image quality was assessed by using a 4-point Likert scale at the level of the PT, lobar, segmental, and subsegmental arteries. Results between groups were reported as mean +/- SD. Results: Two hundred twenty-two patients (94%) were scanned at a kV setting below 100 kV: n = 108 for 70 kV, n = 82 for 80 kV, and n = 32 for 90 kV. Mean CM bolus volume (in milliliters) and total iodine load (in grams of iodine) for 70 to 90 kV were as follows: 24 +/- 3 mL and 7 +/- 1 g I, 29 +/- 4 mL and 9 +/- 2 g I, and 38 +/- 4 mL and 11 +/- 1 g I, respectively. Mean flow rates (in milliliters per second) and iodine delivery rates (in grams of iodine per second) were 3.0 +/- 0.4 mL/s and 0.9 +/- 0.1 g I/s (70 kV), 3.6 +/- 0.4 mL/s and 1.0 +/- 0.1 g I/s (80 kV), and 4.7 +/- 0.5 mL/s and 1.3 +/- 0.1 g I/s (90 kV). Mean radiation doses were 1.3 +/- 0.3 mSv at 70 kV, 1.7 +/- 0.4 mSv at 80 kV, and 2.2 +/- 0.6 mSv at 90 kV. Mean vascular attenuation in the PT for each kV group was as follows: 397 +/- 101 HU for 70 kV, 398 +/- 96 HU for 80 kV, and 378 +/- 100 HU for 90 kV, P = 0.59. Forty-six patients (21%) showed pulmonary embolism on the CTPA. One scan (90 kV) showed nondiagnostic segmental pulmonary arteries, and 5% of subsegmental arteries were of nondiagnostic image quality. All other segments were considered diagnostic-excellent subjective image quality. Conclusions: Simultaneously optimizing both CM injections and kV settings to the individual patient in CTPA results in diagnostic attenuation with on average 24 to 38 mL of CM volume and a low radiation dose for most patients. This individualized protocol may help overcome attenuation-variation problems between patients and kV settings in CTPA.