Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h

Schooler et al.
Injection Sites for CTA in Children

Pediatric Imaging
Original Research

Evaluation of Contrast Injection

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Site Effectiveness: Thoracic CT

Angiography in Children With Hand
Injection of IV Contrast Material
Gary R. Schooler 1 OBJECTIVE. The purpose of this study was to evaluate the effectiveness of various con-
David Zurakowski2 trast injection sites when performing thoracic CT angiography (CTA) using hand injection of
Edward Y. Lee1 IV contrast material in infants and young children with a small IV catheter.
MATERIALS AND METHODS. We used our hospital information system to retro-
Schooler GR, Zurakowski D, Lee EY spectively identify consecutive pediatric patients who underwent thoracic CTA with hand in-
jection of contrast material from August 2012 to July 2013. The study indication for thoracic
CTA was to evaluate the thoracic systemic arterial vasculature and pulmonary venous vascu-
lature. Both qualitative and quantitative evaluation of thoracic CTA image quality was per-
formed by two reviewers independently. Qualitative evaluation of thoracic CTA image qual-
ity was performed by visual assessment of the degree of contrast enhancement in the ROI on
a 4-point scale. Quantitative evaluation was performed by measuring attenuation obtained
with the ROI placed within the aorta at two locations (the level of the aortic arch and at the
level of the carina) to evaluate the thoracic systemic arterial vasculature. For evaluation of the
pulmonary venous system, attenuation measurements were obtained at the center of the left
atrium. Six individual injection sites were identified: head, jugular vein, arm vein, hand vein,
leg vein, and foot vein. Injection sites were categorized into three regional groups: head-neck
region (head vein and jugular veins), upper extremity region (arm and hand veins), and lower
extremity region (leg and foot veins). Comparisons of attenuation values between individual
and regionally grouped contrast injection sites were determined using the F-test in ANOVA.
RESULTS. The study cohort included 50 pediatric patients (29 boys and 21 girls; mean
age, 8 months ± 1 year; range, 1 week to 5 years) who underwent a total of 50 thoracic CTA
studies for evaluating the thoracic systemic arterial vasculature (n = 38; 76%) or pulmonary
venous vasculature (n = 12; 34%). All 50 thoracic CTA studies were of diagnostic quality on
the basis of qualitative evaluation (all ≥ 3). For quantitative evaluation with the threshold for
a diagnostic thoracic CTA study defined as attenuation greater than 150 HU in the ROI, all
50 thoracic CTA studies were technically successful (aortic arch, 380 ± 150 HU; descend-
ing thoracic aorta at the level of the carina, 392 ± 155 HU; and left atrium, 352 ± 90 HU).
Keywords: contrast injection, pediatric patients, thoracic There were no significant differences in mean attenuation between individual injection sites
CT angiography (CTA)
(p > 0.20 for each comparison) or different regional groups (p > 0.50 for each comparison).
DOI:10.2214/AJR.14.12810 CONCLUSION. Diagnostic quality thoracic CTA can be achieved with hand injection
of IV contrast material in infants and young children with a small IV catheter, independent
Received March 7, 2014; accepted after revision of the IV access site.
May 10, 2014.

1
Department of Radiology, Boston Children’s Hospital
and Harvard Medical School, 300 Longwood Ave, Boston,
MA 02115. Address correspondence to E. Y. Lee
(edward.lee@childrens.harvard.edu).
2
Department of Anesthesiology, Boston Children’s
Hospital and Harvard Medical School, Boston, MA.
AJR 2015; 204:423–427
0361–803X/15/2042–423
© American Roentgen Ray Society
T
horacic CT angiography (CTA) is
currently a frequently performed
procedure in the pediatric popula-
tion. CTA, which is a noninvasive
imaging modality, can be used for various clin-
ical indications, including evaluation of con-
genital and acquired intrathoracic vascular ab-
normalities such as vascular rings and sling,
aortic coarctation, pulmonary arteriovenous
malformation, pulmonary sequestration, pul-
monary embolism, and postsurgical vascular
graft and stent patency [1–13]. Thoracic CTA is
faster and safer and associated with less ioniz-
ing radiation than conventional catheter-based
angiography, once regarded as the reference
standard for evaluating the thoracic vascula-
ture. These benefits have further increased the
routine use of thoracic CTA in pediatric pa-
tients in recent years. However, obtaining diag-
nostic quality thoracic CTA with optimal en-
hancement of vessels of interest often is still
challenging, particularly in infants and young

AJR:204, February 2015 423


children because only small IV catheters are
available for contrast administration.
A critical component in successful thorac-
ic CTA in the pediatric patient is the effec-
tive delivery of IV contrast material, which
affects the contrast enhancement of the ves-
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sel of interest. Diagnostic quality thoracic
CTA in pediatric patients can be obtained
when injecting contrast material from vari-
ous peripheral IV access sites [14]. Howev-
er, the previous study was performed using
mechanical injection (i.e., power injection)
of IV contrast material. In infants and young
children with only small peripheral IV cath-
eters, there is concern and reluctance among
radiologists whether mechanical adminis-
tration of IV contrast material is safe and
whether hand injection of contrast material
is effective for obtaining diagnostic quality
thoracic CTA in this patient population.
Unfortunately, there is currently a pau-
city of information regarding the effective-
ness of various contrast injection sites for
performing thoracic CTA with hand injec-
tion of IV contrast material in infants and
young children. Such information, which
can help determine the site of hand injection
of IV contrast material for obtaining diag-
nostic quality thoracic CTA, would be clin-
ically valuable. Therefore, the purpose of
this study was to evaluate the effectiveness
of various contrast injection sites when per-
forming thoracic CTA using hand injection
of IV contrast material in infants and young
children with a small IV catheter.
Materials and Methods
Subjects
The institutional review board approved the
retrospective review of radiologic and clinical
data for this study. The need to obtain patient con-
sent was waived, but patient confidentiality was
protected in accordance with HIPAA guidelines.
We used our hospital information system to
identify consecutive pediatric patients (≤ 18 years
old) who underwent thoracic CTA with hand in-
jection of contrast material from August 2012 to
July 2013. The study indication for thoracic CTA
was to evaluate the thoracic systemic arterial vas-
culature and pulmonary venous vasculature. For
each patient, only the initial thoracic CTA exami-
nation was included for analysis.
From these inclusion criteria, an initial study
cohort of 51 patients was identified who under-
went a total of 51 thoracic CTA examinations.
One pediatric patient who underwent thoracic
CTA for evaluation of systemic thoracic arterial
vasculature using a large femoral line catheter (7
424 AJR:204, February 2015
Schooler et al.
gauge) was excluded from the study. Therefore,
the final study cohort consisted of 50 pediatric pa-
tients who underwent a total of 50 thoracic CTA
studies. Among these 50 thoracic CTA studies, 38
(76%) were performed for evaluation of the sys-
temic thoracic arterial vasculature and 12 (24%)
were performed for evaluation of the pulmonary
venous vasculature.
CT Imaging Technique
Sedation—At our institution, the ability of the
patient to cooperate for thoracic CTA is assessed
in advance by a CT nurse and pediatric anesthe-
siologist. Children more than 4 years old (n = 1;
12%) were able to undergo thoracic CTA without
sedation or general anesthesia, and the remaining
49 patients who were 4 years old or younger re-
quired adjuvant medication for sedation.
IV contrast material—All thoracic CTA exam-
inations were performed using nonionic iodinat-
ed contrast material (iopamidol 370 mg I/mL, Iso-
view, Bracco Diagnostics) at a dose of 1.5 mL/kg
(not to exceed 150 mL). All catheters were care-
fully inspected by a nurse who evaluated the in-
tegrity and patency by flushing the catheter with a
saline solution and confirming blood return before
contrast injection.
The contrast material was hand injected by an
experienced pediatric nurse who was trained to
administer the contrast material at an approximate
rate of 1 mL/s. The injection site was monitored
closely at the time of injection to minimize the
risk of contrast extravasation. The size of the IV
catheter and IV access site for iodinated contrast
injection were recorded at the time of the exam-
ination for each patient. After the completion of
contrast injection and CT, all catheters were eval-
uated for evidence of complications, such as cath-
eter rupture or contrast extravasation. Any com-
plication related to hand injection of the contrast
material was recorded.
Thoracic CTA technique—All of the thorac-
ic CTA studies were performed using a 64-MDCT
scanner (Sensation 64, Siemens Healthcare). Before
acquisition of axial CT images, topographic imag-
es were obtained to determine the area of coverage,
which extended from the thoracic inlet to the level
of the diaphragm. The thoracic CTA study was per-
formed in the supine position at end-inspiration.
All thoracic CTA studies were performed with
the following parameters: 0.6-mm collimation,
weight-based low-dose kilovoltage and tube cur-
rent, high-speed mode, and pitch equivalent of
1.0–1.5. A slice thickness of 1.25 mm was used to
reconstruct the dataset for review of the axial tho-
racic CTA images.
The radiologist or CT technologist initiated ac-
quisition of the thoracic CTA images when the
contrast enhancement of 150 HU or greater was
achieved using bolus-tracking monitoring with
the ROI placed in the left ventricle. When an up-
per extremity IV access site was used, scanning
was performed in an inferior to superior (dia-
phragm to apexes) direction, and when using a
lower extremity IV access site, scanning was per-
formed in a superior to inferior (apexes to dia-
phragm) direction to reduce streak artifact from
the contrast bolus.
Thoracic CTA Image Evaluation
Two board-certified pediatric radiologists inde-
pendently reviewed all thoracic CTA studies. Al-
though both reviewers knew the thoracic CTA stud-
ies were performed for evaluation of thoracic vessels
in children, they were blinded to all other clinical in-
formation, reports of thoracic CTA studies, and re-
sults of prior imaging studies. For CTA image qual-
ity assessment, both quantitative and qualitative
evaluation of image quality was performed.
Qualitative evaluation of thoracic CTA im-
age quality—Qualitative evaluation of thoracic
CTA image quality was performed by visual as-
sessment of the degree of contrast enhancement in
the ROI. The reviewers independently scored each
thoracic CTA study on a 4-point scale that was
based on the degree of contrast enhancement as
follows: 1, unacceptable (nonvisualization of con-
trast material); 2, suboptimal (minimal contrast
opacification); 3, good (sufficient contrast opaci-
fication); and 4, excellent (optimal contrast opaci-
fication). For cases in which there was a discrep-
ancy between the two reviewers’ observations,
the reviewers reevaluated the cases together and
reached a final decision by consensus in a third
review session. Diagnostic quality was considered
to be achieved when the score was 3 or higher.
Quantitative evaluation of thoracic CTA im-
age quality—Quantitative evaluation of thoracic
CTA image quality was performed by assessing
the degree of opacification of the vessels or cardi-
ac chamber of interest with mean attenuation mea-
surements performed on our PACS workstation
(Synapse, Fujifilm Medical Systems). Thorac-
ic CTA images were evaluated in the axial plane
in standard soft-tissue (level, 40–50 HU; width,
400–450 HU) windows.
Measurements were obtained and recorded by
two board-certified pediatric radiologists by plac-
ing an ROI within the vessel of interest that was
equal to one half the diameter of the vessel and po-
sitioned centrally within the lumen of the vessel (at
the level of the midaortic arch and at the level of
the carina) for thoracic CTA studies performed for
evaluation of the systemic thoracic arterial vascula-
ture, a method based on previously reported CT an-
giography quality criteria [15, 16]. A similar meth-
 Injection Sites for CTA in Children

od of mean attenuation measurement was used for
evaluation of the thoracic CTA studies performed
for evaluation of the pulmonary venous vasculature
by placing an ROI one half the diameter of the left
atrium centrally within the chamber. The thorac-
ic CTA studies were considered to have diagnostic
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ment in 48 (96%) of 50 thoracic CTA studies.
For the remaining two thoracic CTA studies
with initial disagreement, the two reviewers
were able to reach a consensus. All 50 tho-
racic CTA studies were technically success-
ful, showing good (grade 3, n = 7, 14%) or
racic aorta at the level of the carina, 464 ± 219
HU, and left atrium: 370 ± 23 HU; hand vein–
aortic arch, 366 ± 120 HU, descending tho-
racic aorta at the level of the carina, 377 ± 127
HU, left atrium, 399 ± 173 HU; leg vein–aor-
tic arch: 546 HU, descending thoracic aorta at

opacification of the vessels or cardiac chamber of
interest when the measured mean attenuation value
was 150 HU or greater [15, 17].
Statistical Analysis
Age, sex, and descriptive statistics were report-
ed. To ascertain image quality of thoracic CTA
on the basis of hand injection of IV contrast ma-
terial, attenuation values for the aortic arch, de-
scending thoracic aorta, and left atrium were com-
pared among six injection sites and three regional
groups by ANOVA and summarized by means
and standard deviations. Statistical analysis was
performed using SPSS Statistics, version 21.0
(IBM). Two-tailed p values less than 0.05 were
considered statistically significant [18].
Results
Patient Population
Our study population consisted of 50
pediatric patients, 29 boys (57%) and 21
girls (43%) with a mean age (± SD) of 8
months ± 1 year, (range, 1 week to 5 years).
All 50 thoracic CTA studies were performed
without complications.
excellent (grade 4, n = 43, 86%) contrast en-
hancement in the ROI on visual qualitative
assessment by two independent reviewers
(Fig. 1). No thoracic CTA study showed poor
or limited degree of contrast enhancement.
Quantitative assessment—All 50 thoracic
CTA studies were technically successful on
the basis of quantitative assessment. The over-
all mean attenuation and SD for all injection
sites was aortic arch, 380 ± 150 HU; descend-
ing thoracic aorta at the level of the carina,
392 ± 155 HU; and left atrium, 352 ± 90 HU.
Individual IV access sites—The mean at-
tenuation and SD measurements at individu-
al IV access sites were as follows: head vein–
aortic arch: 511 HU, descending thoracic
aorta at the level of the carina, 546 HU; jugu-
lar vein–aortic arch, 261 HU, descending tho-
racic aorta at the level of the carina, 266 HU,
and left atrium 344 HU ± 62 SD; arm vein–
aortic arch, 447 ± 217 HU, descending tho-
the level of the carina, 603 HU; foot vein–aor-
tic arch: 337 ± 122 HU, descending thoracic
aorta at the level of the carina, 337 ± 112 HU,
and left atrium: 321 ± 40 HU.
There was no statistically significant differ-
ence in attenuation measurement values among
the six different individual IV access injection
sites at the level of the aortic arch (p = 0.38),
descending thoracic aorta at the level of the ca-
rina (p = 0.211), or left atrium (p = 0.37) (p >
0.20 for each comparison, ANOVA).
Grouped IV access sites—Mean attenu-
ation measurements within the three groups
were as follows (Fig. 2): head-neck group
(n = 4): aortic arch, 386 ± 177 HU, descend-
ing thoracic aorta at the level of the carina,
406 ± 198 HU, and left atrium: 344 ± 88 HU;
upper extremity group (n = 27): aortic arch,
399 ± 167 HU, descending thoracic aorta at
the level of the carina, 413 ± 172 HU, and left
atrium: 387 ± 124 HU; and lower extremity

Location of IV Catheters
Six IV access sites for contrast injection
were identified: head (n = 1, 2%), jugular
vein (n = 3, 6%), arm vein (n = 11, 22%),
A
hand vein (n = 16, 32%), leg vein (n = 1,
2%), and foot vein (n = 18, 36%). When in-
jection sites were categorized into three re-
gional groups, there were four (8%) in the
head-neck region (head and jugular veins),
27 (54%) in the upper extremity region (arm
and hand veins), and 19 (38%) in the lower
extremity region (leg and foot veins).
B
Size of IV Catheters
The pediatric patients included in our
study underwent thoracic CTA studies with
an indwelling catheter size of 22 gauge (n =
16, 32%) or 24 gauge (n = 34, 68%).

Contrast Enhancement
The results of the subjective (qualitative
assessment) and the objective (quantitative
assessment) of thoracic CTA image quality
will be presented next.
Qualitative assessment—The two review-
ers’ qualitative assessments were in agree-
C
Fig. 1—Sites at which ROIs were placed and used for qualitative and quantitative evaluation of vessel or
chamber of interest opacification.
A–C, CT images show ROI (arrow) at level of aortic arch (A), ROI (arrow) at level of carina in descending
thoracic aorta (B), and ROI (asterisk) placed centrally within left atrium (C) when evaluating pulmonary venous
structures for grouped injection sites within head-neck, upper extremity, and lower extremity regions. Actual
attenuation measurements from ROI within selected images are provided for reference.

AJR:204, February 2015 425


900
800
700
p = 0.57
600 p = 0.68
Attenuation (HU)
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500
400
300
200
100
0 at level of carina (p = 0.57),
Aortic Arch Descending
Thoracic Aorta
group (n = 19): aortic arch, 352 ± 130 HU, de-
scending thoracic aorta at the level of the ca-
rina, 356 ± 129 HU, and left atrium: 322 ± 40.
There was no statistical difference in attenu-
ation measurements among the three injection
site groups at the level of the aortic arch (p =
0.68), descending thoracic aorta at the level of
the carina (p = 0.57), or left atrium (p = 0.54)
(p > 0.50 for each comparison, ANOVA).
Discussion
The results from our study show that when
hand injection of IV contrast material for
thoracic CTA is used, a diagnostic examina-
tion can be obtained from all six different IV
injection sites (head, jugular, arm, hand, leg,
and foot veins) in infants and young children
with a small IV catheter. No statistically sig-
nificant difference was identified in the at-
tenuation measurements obtained from the
thoracic vessels or cardiac chambers of inter-
est when evaluating the different IV injection
sites for both individual and grouped IV ac-
cess sites. Our findings thus support the use
of hand injection of IV contrast material in
infants and young children with only avail-
able small IV catheters when thoracic CTA
studies are performed.
To our knowledge, our study is the first
to evaluate contrast injection site effective-
ness when performing thoracic CTA studies
in infants and young children with small IV
catheters via hand injection of contrast ma-
terial. Because of the small body size, it is
often possible to place only a small IV cath-
eter in infants and young children under-
going thoracic CTA, which requires a high
degree of contrast enhancement for an ac-
curate diagnosis. Our findings confirm and
expand on those of a previous study focused
on image quality in pediatric cardiovascular
426 AJR:204, February 2015
Schooler et al.
Fig. 2—Graph shows
average attenuation values
calculated for aortic arch,
descending thoracic aorta,
and left atrium grouped by
IV contrast injection site:
head-neck vein (white),
p = 0.54
upper extremity vein
(gray), lower extremity vein
(black). Bars for p value
are provided for reference.
There was no statistical
difference in attenuation
measurements among three
injection site groups at level
of aortic arch (p = 0.68),
descending thoracic aorta
Left Atrium or left atrium (p = 0.54).
CTA from different contrast injection sites
by Yang et al. [14]. In that study, the inves-
tigators showed that mechanical injection of
contrast material via head, arm, and leg vein
injection sites can yield diagnostic cardio-
vascular CTA studies in infants and young
children. The results of our study support the
findings of their study that diagnostic-quali-
ty thoracic CTA studies can be obtained with
administration of IV contrast material via
various injection sites in infants and young
children. However, the difference between
our study and that of Yang et al. is the differ-
ent method of administering IV contrast ma-
terial. Although mechanical injection of IV
contrast material was used in their study, we
used hand injection of IV contrast material
in our study. The results of our study show a
new finding that hand injection via these IV
contrast injection sites in infants and young
children can also result in diagnostic-quality
thoracic CTA studies.
When using hand injection of IV contrast
material for thoracic CTA studies in infants
and young children, it is crucial to initiate
scanning when optimal contrast enhancement
(> 150 HU) is achieved in the region of inter-
est [15, 17]. Our CT technique using the bolus
tracking method to decide when to initiate CT
ensured that thoracic CTA studies would be of
diagnostic quality. We believe the bolus track-
ing method should be considered for CT, par-
ticularly when hand injection of IV contrast
material is used for thoracic CTA studies in
this pediatric population.
When thoracic CTA is performed, ade-
quate delivery of contrast material is abso-
lutely necessary for obtaining sufficient vas-
cular contrast enhancement for an accurate
diagnosis. Despite multiple prior studies that
have shown it is both safe and effective to per-
form mechanical injection of contrast materi-
al through both central and peripheral venous
access devices in the pediatric population [19–
21], many imaging centers are often reluctant
to use mechanical injection of contrast mate-
rial in infants and young children via a small-
caliber IV catheter, mainly because of the po-
tential complications of catheter rupture or
contrast extravasation. To avoid mechanical
injection of contrast material in this pediat-
ric population, contrast material can be hand
injected, but the effectiveness of hand injec-
tion of contrast material at different injection
sites with a small IV catheter has often been
questioned. From a practical standpoint, the
combined results of the previously published
study and our study suggest that both mechan-
ical and hand injection of contrast material via
a small IV catheter at various injection sites
can provide diagnostic-quality thoracic CTA
studies in infants and young children.
Although one study in adults indicated no
statistically significant difference in the inci-
dence of contrast extravasation at the IV ac-
cess site when comparing mechanical and
hand injection methods of contrast materi-
al delivery [22], there is a paucity of litera-
ture currently available regarding the safety
of hand injection of IV contrast material via
peripheral IV access, particularly in the pe-
diatric population. Much of the available lit-
erature focuses on the safety of contrast ad-
ministration via central venous catheter,
particularly by mechanical administration. A
study measuring in vitro pressure generated
within central venous catheters by hand injec-
tion of contrast material compared with pow-
er injection of contrast material revealed that
hand injection tended to have a higher peak
pressure for equivalent average flow rates
when compared with mechanical injection
[23]. In our patient population, all 50 CTA
studies were performed without complica-
tion, including those related to contrast media
administration, which somewhat ensures the
safety of hand injection of IV contrast mate-
rial in infants and young children with a small
IV catheter. However, we believe that future
studies consisting of larger study populations
are needed to better elucidate the safety of
hand injection of contrast material via small
peripheral IV sites in the pediatric population.
We recognize that there are several poten-
tial limitations to our study. First, the patient
population size of our study was modest. Con-
sidering our relatively modest study popula-
tion, a future multicenter study with a larger
patient population is necessary to confirm our

preliminary recommendation that hand injec-
tion is sufficient for obtaining diagnostic tho-
racic CTA in infants and young children with
a small IV catheter at various access sites.
Second, we recognize that the mean age of 8
months in our patient population is young and
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may not provide an accurate representation of
results in an older pediatric patient population.
However, we emphasize that, in clinical prac-
tice, many of the patients who undergo tho-
racic CTA under the conditions in our study,
with hand injection of IV contrast material and
variable IV access sites, are infants and young
children. Older children with secure and larg-
er peripheral IV access typically undergo tho-
racic CTA studies with mechanical injection of
IV contrast material similar to the adult pop-
ulation. Third, vascular contrast enhancement
largely depends on the contrast injection rate.
Because of the hand injection of contrast ma-
terial evaluated in our study, contrast injection
rates could not be standardized. However, we
expect the variability in the contrast injection
rate to be small when the hand injection tech-
nique is used by an experienced pediatric nurse
trained to administer the contrast material at
an approximate rate of 1 mL/s.
In conclusion, our data show that diag-
nostic quality thoracic CTA can be achieved
with hand injection of IV contrast material
in infants and young children independent
of IV access sites. We believe the results of
our study can be used by the radiologists who
often have to make a decision regarding the
use of hand injection of IV contrast material
in infants and young children with a small
IV catheter at various access sites when per-
forming thoracic CTA.
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