Radiology

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Delayed Helical CT Acquisition in the Detection of

Endoleak [letter]
From:
Jafar Golzarian, MD
Department of Radiology, University of Iowa
200 Hawkins Drive, 3957 JPP, Iowa City, IA 52242
e-mail: jafar-golzarian@uiowa.edu
Editor:
I read with interest the article by Dr Rozenblit and colleagues
in the May 2003 issue of Radiology (1), in which they demonstrate the role of delayed acquisition of computed tomographic (CT) images in the evaluation of endoleak. Although
the authors used a CT protocol that changes in relation to the
technical evolution of CT scanners, their results confirm our
findings when we first reported the importance of using
delayed acquisition with biphasic helical CT (2). Very few
articles are available on this topic. While it is generally accepted that CT follow-up should include delayed acquisition
in patients after endoluminal repair of aortic aneurysms,
there is not a standardized CT technique that has been widely
accepted.
The initial CT technique at the time of publication of our
article was based on our ongoing protocol used since 1994,
with use of 5-mm section thickness. Like Dr Rozenblit and
colleagues, we have changed our protocol to a 3-mm thickness and pitch of 2 (3). However, the delayed acquisition
needs to be performed with the exact same parameters used
for arterial phase acquisition. Moreover, the sections should
be acquired with the same table position to be correctly
comparable and allow detection of small leaks. It is for this
reason that we acquire delayed images starting at the same
proximal level (1 cm above the proximal end of the stentgraft) as that used for arterial phase images, with the same
collimation.
To reduce the radiation dose, the delayed acquisition covers only the volume containing the stent-graft. With regard
to unenhanced CT, we believe that with the above technique,
there is no need to obtain systematically unenhanced acquisitions. If at the end of the delayed acquisition there is still a
concern, another delayed section (obtained 1 minute after
the end of the delayed phase) can still be acquired at the same
table position to allow the distinction between calcifications
and small leaks.
I would like to congratulate the authors again for this
interesting article.
References
1. Rozenblit AM, Patlas M, Rosenbaum AT, et al. Detection of
endoleaks after endovascular repair of abdominal aortic aneuVolume 230

Number 1

rysm: value of unenhanced and delayed helical CT acquisitions.

Radiology 2003; 227:426 433.
2. Golzarian J, Dussaussois L, Abada HT, et al. Helical CT of the
aorta after endoluminal stent-graft therapy: value of biphasic
acquisition. AJR Am J Roentgenol 1998; 171:329 331.
3. Golzarian J, Dussaussois L, Struyven J. Imaging of abdominal
aortic aneurysms after endoluminal repair. Semin Ultrasound
CT MR 1999; 20:16 24.

Dr Rozenblit and colleagues respond:

We thank Dr Golzarian for his interest in our study (1) and
appreciate his comments. We share his opinion that the
craniocaudal extent of the delayed CT acquisition should be
limited to the endovascular stent-graft for the reduction of
radiation exposure; this is our technique, as well. Our study
findings confirm those of Dr Golzarian and colleagues (2,3)
regarding the value of delayed CT for detection of endoleaks.
However, our delayed CT acquisitions are obtained with
thicker sections than those used with arterial phase CT for
two reasons. First, we use the delayed series specifically for
the detection of low-flow endoleaks, which, we believe, do
not require thin sections because of their relatively large size.
Second, we do not need to use the delayed series to differentiate calcifications from endoleaks, since this is accomplished
by comparing the arterial phase images with the unenhanced
images.
Dr Golzarian states, the delayed acquisition needs to be
performed with the exact same parameters used for arterial
phase acquisition. This may perhaps be necessary for biphasic CT images obtained without correlative unenhanced CT
images. The use of identical section thicknesses and locations
for the two series might then be of value to help avoid
indeterminate results. Unfortunately, we have not found references on the evaluation of the specificity of this technique
for the detection of endoleaks. In the biphasic arm of our
study, which did not involve use of identical parameters for
both series, we had a 20% indeterminate rate for endoleaks.
Dr Golzarian believes that there is no need to obtain
systematically unenhanced acquisitions, and that patients
should be monitored prospectively during scanning to identify those who need additional delayed imaging for differentiation between endoleak and calcifications. This is a valid
approach. However, it cannot be implemented in our practice, because the monitoring of routine outpatient CT scanning is not feasible. We also believe that unenhanced CT is
an integral part of a CT angiographic study, analogous to a
mask image obtained for digital subtraction angiography.
Other authors report a similar approach to the role of the
unenhanced CT scan (4,5) in CT angiography. Unfortunately, prospective randomized studies have not been performed to compare the effectiveness of different approaches
to CT angiography of endografts.

References
1. Rozenblit AM, Patlas M, Rosenbaum AT, et al. Detection of
endoleaks after endovascular repair of abdominal aortic aneurysm: value of unenhanced and delayed helical CT acquisitions.
Radiology 2003; 227:426 433.
2. Golzarian J, Dussaussois L, Abada HT, et al. Helical CT of the
Radiology

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Radiology

aorta after endoluminal stent-graft therapy: value of biphasic

acquisition. AJR Am J Roentgenol 1998; 171:329 331.
3. Golzarian J, Dussaussois L. Struyven J. Imaging of abdominal
aortic aneurysms after endoluminal repair. Semin Ultrasound
CT MR 1999; 20:16 24.
4. Dorffner R, Thurnher S, Youssefzadeh S, et al. Spiral CT angiography in the assessment of abdominal aortic aneurysms after
stent grafting: value of maximum intensity projections. J Comput Assist Tomogr 1997; 21:472 477.
5. Sawhney R, Kerlan RK, Wall SD, et al. Analysis of initial CT
findings after endovascular repair of abdominal aortic aneurysm. Radiology 2001; 220:157160.

Alla M. Rozenblit, MD, Mitchell P. Laks, MD, Zina J. Ricci,

MD
Department of Radiology, Albert Einstein College of
Medicine, Montefiore Medical Center
111 East 210th Street, Bronx, NY 10467

300

Radiology

January 2004