Effect of reduced x-ray tube voltage, low iodine concentration contrast medium, and sinogram-affirmed iterative reconstruction on image quality and radiation dose at coronary CT angiography: results of the prospective multicenter REALISE trial

Abstract

Background: Both low tube voltage and sinogram-affirmed iterative reconstruction (IR) techniques hold promise to decrease radiation dose at coronary CT angiography (CCTA). The increased iodine contrast at low tube voltage allows for minimizing iodine load.

Objective: To assess the effect of reduced x-ray tube voltage, low iodine concentration contrast medium and IR on image quality and radiation dose at CCTA.

Methods: Two hundred thirty-one consecutive patients with suspected coronary artery disease were enrolled in this prospective, multicenter trial and randomized to 1 of 2 dual-source CCTA protocols: 120-kVp with 370 mgI/mL iopromide or iopamidol (n = 116; 44 women; 55.3 ± 9.8 years) or 100 kVp with 270 mgI/mL iodixanol (n = 115; 48 women; 54.2 ± 10.4 years). Reconstruction was performed with filtered back projection and IR. Attenuation, image noise, signal-to-noise ratio, and contrast-to-noise ratio were measured and image quality scored. Size-specific dose estimates and effective doses were calculated.

Results: There were no significant differences in mean arterial attenuation (406.6 ± 76.7 vs 409.7 ± 65.2 Hounsfield units; P = .739), image noise (18.7 ± 3.8 vs 17.9 ± 3.4 Hounsfield units; P = .138), signal-to-noise ratio (22.5 ± 5.4 vs 23.7 ± 6.1; P = .126), contrast-to-noise ratio (17.5 ± 5.5 vs 18.3 ± 6.1; P = .286), or image quality scores (4.1 ± 0.9 vs 4.0 ± 0.9; P > .05) between 120-kVp filtered back projection-reconstructed and 100-kVp IR-reconstructed series. Mean iodine dose was 26.5% lower (18.3 ± 0.5 vs 24.9 ± 0.9 g; P < .0001), mean size-specific dose estimate was 35.1% lower (17.9 ± 6.6 vs 27.5 ± 8.2 mGy; P < .0001), and effective dose was 34.9% lower (2.3 ± 1.0 vs 3.5 ± 1.1 mSv; P < .0001) with the 100 kVp compared with the 120-kVp protocol, respectively.

Conclusion: Using low x-ray tube voltage and IR allows for decreasing the iodine load and effective radiation dose at CCTA while maintaining image quality.

Keywords: Contrast agent; Coronary CT angiography; Imaging optimization; Iterative reconstruction; Radiation exposure.