Contrast Use in CTA Applications

CT angiography of the
lower extremities
The peripheral vascular system presents unique imaging challenges.
Geoffrey D. Rubin, MD and Dominik Fleischmann, MD
Dr. Rubin is an Associate Professor of Radiology and Section Chief of Cardiovascular Imaging, and Dr. Fleishmann is
an Assistant Professor of Radiology at Stanford University School of Medicine, Palo Alto, CA.

omputed tomography (CT) is a

simple and robust method for
evaluating the peripheral arterial
system and for diagnosing peripheral arterial disease. Advances in technology and
variability in patient physiology make
contrast administration challenging, however. This article will review patient
preparation for CT angiography (CTA)
of the lower extremities, as well as optimal scanner settings, contrast administration, and visualization techniques.

The essentials
A multirow scanner is essential for
CTA of the lower extremities; however,
the number of detector rows the scanner
is equipped with (4, 8, or 16) is of less
importance. In fact, all of the clinical
studies of lower-extremity CTA reported
in the scientific literature to date have
been conducted on 4-row scanners, with
impressive results.1-5
Several very practical details are important in ensuring the success of lowerextremity CTA. It is recommended that
tape be used to keep the patients knees
and feet together. (Usually, at our institution, we wrap a pillowcase or towel
around the knees and feet first.) Without
tape, the patients natural inclination is to
let the knees fall away from one another. If
that happens, the field-of-view in the reconstruction must be opened substantially
in order to include the proximal anterior

July 2004

tibial arteries, and in-plane resolution is

lost. The patient must not have a pillow
under the knees, however, as the arterial
system will move up and down relative to
the table, which creates a similar problem
for the reconstruction field-of-view.
The patient should be positioned near
the isocenter of the scanner. Centering
the patient provides the best in-plane and
through-plane resolution for visualizing
what are frequently very tiny vessels.
We use a 20-gauge antecubital intravenous line for contrast delivery, and
nonionic iodinated contrast material. The
scanning range for most studies is from
the celiac artery through the toes, a total
of 105 to 130 cm, depending on the
height of the patient. The entire study
takes about 20 minutes to perform.
Three-dimensional (3D) visualization is
essential. Volume renderings, maximum
intensity projections (MIPs) and curved
planar reformation (CPRs) are all useful
visualization methods.

Scanner settings
There are a range of approaches to
image acquisition, depending on the
detector configuration and the desired
coverage. Full anatomic coverage, from
the celiac arteries through the toes (105
to 130 cm), is generally indicated for the
evaluation of atherosclerotic occlusive
disease. More limited distal coverage (40
to 60 cm) is typically indicated prior to

reconstructive surgery, including fibular

transfer grafts and pectoral flap mobilization for revascularization of an area of
osteomyelitis or tissue injury secondary
to trauma.
Figure 1 describes available detector
configurations for full anatomic coverage,
using a 4-, 8-, or 16-row scanner. In each
case, only 1 configuration emerges as an
acceptable choice. For example, with a 4channel scanner, a 2.5- to 3.0-mm collimation will accomplish the study in 30 to
40 seconds, whereas a 1.0- to 1.5-mm collimation will result in an unacceptably
slow image acquisition. With an 8-channel scanner, by comparison, a detector
collimation of 2.5 to 3 mm is seldom used,
because a higher-resolution alternative
is available (8 1.0 to 1.5 mm). With the
16-row scanner, a 0.5- to 0.75-mm collimation results in excessive image noise,
particularly in the abdomen and pelvis. A
1.0- to 1.5-mm collimation accomplishes
the study in 15 to 20 seconds, with an
acceptable noise level.
Figure 3 shows a full-coverage acquisition from above the celiac arteries through
the feet, using a 4 2.5-mm detector collimation. The patient had claudication, and
femoral pulses were absent. The scan
reveals occlusion of the distal abdominal
aorta, proximal common iliac, and left
superficial femoral arteries, with extensive collateralization reconstituting the
lower extremity arterial system.

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Contrast Use in CTA Applications

FIGURE 1. Detector configurations for a full anatomic scan, from the FIGURE 2. Detector configurations for distal scan, from knees to feet.
celiac arteries to the feet.

The study took approximately 70 seconds to complete. With 2.5-mm-thick

sections, the vessels are a little less distinct than they are with thinner sections,
but image quality is more than adequate
for making important observations on
vessel patency and stenosis, and for guiding routine therapy.
Figure 4 demonstrates a study of distal anatomy, acquired with a 4-row scanner and a 1.5-mm detector collimation.
This patient had osteomyelitis and was
preparing to undergo surgery to revascularize the distal calf. The MIPs depict the
arterial system with the intricate detail
necessary for surgical planning.
The images in Figure 5 were acquired
with 16-row scanner and a 0.625-mm
detector collimation. In this patient with
a tibial plateau fracture, CTA was performed to determine whether the popliteal artery had been injured. There is no
occlusion and no extravasation of contrast
material. Such studies have become a common application of CTA in our practice.

Contrast delivery
For all their advantages, fast scan
acquisitions can complicate contrast
delivery. Table 1 outlines three protocols
we have used for peripheral runoff stud-

46

ies performed on 4-, 8-, and 16-row

scanners. A total of 89 patients are represented. (Unpublished data.)
There is an almost 4-fold reduction in
image acquisition time when comparing
a 4-row scanner with a 16-row scanner.
Enhancement is not necessarily better
with the 16-row scanner, however.
Defined as the average arterial attenuation from the aorta to the feet, enhancement increases substantially when going
from a 4-row to an 8-row scanner,
because contrast delivery is much faster.
Similarly, contrast efficiency, defined as
average enhancement divided by the
iodine load and normalized to the coverage distance, goes up by about 50%.
Contrast efficiency improves further
with the 16-row scanner. Average attenuation drops, however, because there is not
as much time for the contrast bolus to fully
develop and opacify the vessels. Whether
such differences in attenuation affect the
accuracy of diagnosis or clinical management decisions is yet to be determined.
Certain aspects of contrast utilization
are unique to imaging the peripheral vasculature. A separate study, as yet unpublished, by Dominik Fleischmann, MD, at
our institution, examined peripheral arterial enhancement in 20 patients with

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peripheral arterial occlusive disease.

After injecting a small test-bolus, Fleischmann observed an aortic contrast transit
time of 14 to 28 seconds, with a mean of
20 secondsstandard findings for aortic
CTA. To measure the contrast transit time
between the aorta and the popliteal artery,
he injected a second contrast bolus and
documented its arrival in the popliteal
artery. The aortopopliteal transit time
averaged 10 seconds, representing an
average contrast flow rate of 65 mm/sec.
There was substantial variability among
patients, however, with a minimum of
4 seconds (177 mm/sec) and a maximum
of 24 seconds (30 mm/sec)almost a
4-fold difference. What is intriguing is that
it confirms angiographic experience, as
there was no correlation between contrast
flow rate and clinical stage of disease.
Therefore, contrast transit times are
not predictable by any means other than
direct measurement.
Table 2 presents the effect of contrast
flow rates on scanning parameters.
With a slower scan (detector collimation: 4 2.5 mm, 8 1.25 mm, or 16
0.625 mm), table speed is 30 mm/sec.
The time it takes to scan from aorta to
ankle, or a distance of about 1200 mm,
is 40 seconds. In a patient with a low

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Contrast Use in CTA Applications

A

FIGURE 3. (A and B) Full-coverage acquisition from above the

celiac arteries through the feet, using a 4- 2.5-mm detector collimation (frontal and lateral maximum intensity projections). The
patient had claudication, and femoral pulses were absent. The scan
reveals occlusion of the distal abdominal aorta, proximal common
iliac, and left superficial femoral arteries, with extensive collateralization reconstituting the vascular system. The study took approximately 70 seconds to complete. (Reprinted with permission from
Rubin GD, Schmidt AJ, Logan LJ, Sofilos MC. Multidetector row CT
angiography of lower extremity arterial inflow and runoff: Initial experience. Radiology. 2001;221:146-168.1)

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FIGURE 4. Study of distal anatomy, acquired with a 4-row scanner and

a 1.5-mm detector collimation. This patient had osteomyelitis and was
preparing to undergo surgery to revascularize the distal calf. The maximum intensity projection images depict the arterial system in the
exquisite detail necessary for surgical planning. (Reprinted with permission from Rubin GD, Schmidt AJ, Logan LJ, Sofilos MC. Multidetector
row CT angiography of lower extremity arterial inflow and runoff: Initial
experience. Radiology. 2001;221:146-168.1)

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Contrast Use in CTA Applications

B

FIGURE 5. (A) Frontal volume-rendered image. (B) Posterior oblique volume-rendered image. (C) Cranial oblique volume-rendered image
following digital disarticulation of the femur and patella. Images acquired with a 16-row scanner and a 0.625-mm detector collimation. In this
patient with a tibial plateau fracture, CTA was performed to determine whether the popliteal artery had been injured. There is no occlusion
and no extravasation of contrast material.

Table 1. Peripheral runoff studies (n = 89)

Scanner
Rotation time (sec)
Detector configuration
Scan time (sec)
Contrast concentration (mgI/mL)
Iodine dose (g)
Attenuation (HU)
Contrast efficiency (HU/gImm)

4-row
0.8
4 2.5
70
300
54
282
6.4

8-row
0.5
8 1.25
44
350
58.8
418
9.1

16-row
0.5
16 1.25
22
350
42
365
11.5

Data collected by Alessandro Napoli, MD. (Unpublished data.)

blood flow rate (30 mm/sec), contrast

flows in perfect synchrony with the
table speed. In a patient with an average blood flow rate, however, contrast
flow from aorta to ankle outpaces the
table speed. The contrast bolus must be
at least 22 seconds long to ensure that
opacification is still adequate as the
foot is being scanned. In a patient with

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a fast blood flow rate (177 mm/sec), the

contrast bolus must be at least 33 seconds in length.
With faster scans (detector collimation: 8 2.5 mm or 16 1.25 mm), the
time it takes to scan from aorta to ankle
is only 20 seconds. In a patient with a
slow blood flow rate, the scanner can
outrun the contrast bolus, rather than

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lagging behind it. In some patients, this

has created a challenge when attempting to examine vessels in the feet using a
16 1.25-mm detector collimation. In
such cases, it is necessary to wait 20 seconds after contrast arrival in the aorta to
begin the scan, so that the vessels of the
feet are opacified at the time of data
acquisition. (The goal is to image the tail
of the bolus in the abdomen and the head
of the bolus in the feet).
Because there is substantial and
unpredictable variability among patients
in lower-extremity flow rates, the best
approach appears to be the use of a long
contrast bolus30 to 35 secondsin all
cases. In short, bolus duration is driven
not by the speed of the scan but by the
need to ensure that the entire arterial system, from aorta to feet, is opacified at the
time of image acquisition.

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Contrast Use in CTA Applications

Table 2. Influence of contrast flow rates on image acquisition

Blood
flow
(mm/sec)
30
65
177

Contrast travel
time to ankle
(sec)
40
18
7

Slow scanDetector collimation:

4 2.5, 8 1.25, 16 0.625
Table speed = 30 mm/sec
CT table travel
Min.
time to ankle
bolus length
(sec)
(mm)
40
0
40
22
40
33

Fast scanDetector collimation:

8 2.5, 16 1.25
Table speed = 60 mm/sec
CT table travel
Min.
time to ankle
bolus length
(sec)
(sec)
20
(20)
20
2
20
13

Aorta to ankle distance = 1200 mm.

Data collected by Dominik Fleischmann, MD. (Unpublished data.)

Determining the optimal time to begin

image acquisition is more complex than
merely fitting the contrast bolus into the
scan range, however. It may not be desirable
to image just as the bolus arrives. The intensity of enhancement builds up over time,
so the distal end of the bolus is far more
enhancing than it is at the proximal end.6
How the scan will be triggered is another
important consideration in determining
how much contrast to deliver. There are
two fundamental ways to determine the
delay from venous injection of contrast
material to enhancement of the abdominal
aorta. The first is to use a preliminary test
bolus. With this approach, the time to peak
contrast enhancement directly measures
contrast medium transit time. Direct bolus
triggering is the other approach. Automated or visual detection of contrast arrival,
defined by a predetermined attenuation
threshold, triggers scanning.
The length of the contrast bolus will
depend on whether scan timing is determined by a test bolus or bolus triggering.
Assume that a 30- to 35-second injection
is needed to ensure adequate opacification of the entire periphery in the majority of patients. That bolus size will be
sufficient if scan timing is determined by
a preliminary test injection. A longer
bolus will be necessary, however, if scan
timing is determined by bolus triggering,
because of the delay between the time of
contrast arrival at the abdominal aorta
and the actual triggering of the scan. This
delay varies from one scanner to another,

July 2004

but it can be up to 8 seconds. If the delay

is 8 seconds, then a 38- to 43-second contrast bolus will be needed.
With fast scanning, scanning should be
delayed by 20 seconds, even if a test bolus
or bolus triggering is used. (It is not necessary to add 8 seconds to the bolus length t
o account for the delays associated with
bolus triggering, however.) The benefit of
the 20-second delay is that imaging takes
place later in the rising contrast enhancement curve, which potentially results in
more homogeneous and intense opacification throughout the acquisition.
A further complication of contrast
delivery is that blood flow in the legs
may be asymmetric if, for example, there
is a tight stenosis or aneurysm on only
one side. In such cases, use of an even
longer contrast bolus may be warranted.
Venous opacification may make it
more difficult to evaluate the arterial system in certain cases. Early venous opacification almost always occurs in cases of
ipsilateral inflammation, resulting from
cellulitis or ischemic ulceration. Both are
common in patients with peripheral vascular disease. Occasionally, venous
opacification is attributable to spontaneous arteriovenous shunting, which in
patients with atherosclerotic occlusive
disease is likely due to plaque rupture in
small vessels.

Visualization techniques
Maximum-intensity projections provide a useful overview of the peripheral

vessels. To effectively use MIPs in the

periphery, however, bone must be edited
out. This is a time-intensive endeavor,
although tools are becoming available to
make it more efficient. In addition, calcification can obscure underlying vessels.
Curved planar reformations are longitudinal sections along the length of the
vessel. A CPR enables visualization of
both soft and hard plaque and is especially useful in cases of circumferential
calcium, where it permits examination of
the lumen adjacent to the calcium,
including regions of stenosis. In addition,
no bone editing is necessary.
A CPR does not provide as good an
overview of the peripheral vasculature
as does the MIP, however. In addition,
this technique is insufficient unless window and level settings are optimized.
When evaluating calcification in peripheral arteries, for example, it is important
to use a bone window to avoiding
blooming and overestimation of calcification size. In very small vessels, such
as the peroneal artery, even a CPR may
not be able to discriminate arterial lumen
from calcification.

Conclusion
CT has become a simple and robust
method for assessing the peripheral arterial system and diagnosing peripheral
arterial disease. Optimization of contrast
administration is increasingly challenging as scanner speeds increase. New
ways to evaluate each patients circula-

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Contrast Use in CTA Applications

tory physiology and compensate for it
when administering contrast material
are needed.
Advances in scanner speed are unlikely
to reduce the volume of contrast used during examination of the peripheral vascular
system but will improve image resolution.
Finally, additional detector rows create
additional data to analyze. We must continue to find more effective and automated
ways to manipulate and process such large
data sets.

REFERENCES
1. Rubin GD, Schmidt AJ, Logan LJ, Sofilos MC. Multidetector row CT angiography of lower extremity arterial
inflow and runoff: Initial experience. Radiology.2001;
221:146-158.
2. Martin ML, Tay KH, Flak B, et al. Multidetector CT
angiography of the aortoiliac system and lower extremities: A prospective comparison with digital subtraction angiography. AJR Am J Roentgenol. 2003;
180:1085-1091.
3. Ofer A, Nitecki SS, Linn S, et al. Multidetector CT
angiography of peripheral vascular disease: A
prospective comparison with intraarterial digital subtraction angiography. AJR Am J Roentgenol. 2003;
180:719-724.
4. Catalano C, Fraioli F, Laghi A, et al. Infrarenal aortic
and lower-extremity arterial disease: Diagnostic performance of multi-detector row CT angiography. Radiology. 2004;231:555-563.
5. Ota H, Takase K, Igarashi K, et al. MDCT compared
with digital subtraction angiography for assessment of
lower extremity arterial occlusive disease: Importance
of reviewing cross-sectional images. AJR Am J
Roentgenol. 2004;182:201-209.
6. Fleischmann D. Present and future trends in multiple
detector-row CT applications: CT angiography. Eur
Radiol. 2002;12 (suppl 2):S11-S15.

Discussion
LEO P. LAWLER, MD, FRCR:
Geoff, thank you; it was a very good
talk. I agree that nothing exposes our
deficiency in terms of our understanding
of contrast dynamics as much as multidetector CT. It seems to me, however,
that as we go forward with peripheral
vascular imaging, it will require some
way of knowing what the Hounsfield
units are doing both in the arteries and
the veins as you scan, knowing what is
happening both proximally and distally.
Then, somehow, you could feed that
back to the table pitch. That seems to me
the only way forward to stop venous

50

contamination and to make sure asymmetric inflow disease is imminent. What

are your thoughts?
GEOFFREY D. RUBIN, MD:
With respect to venous contamination, I
think we are in much better shape with
CT than with MR. It seems to me that
venous contamination typically only
occurs in a pathologic setting in which
we have abnormal arteriovenous shunting. In many respects, I like to be able to
know that it is there and to see it. So I am
not sure that it is a big problem moving
forward.
But what you have said about being
able to somehow detect and compensate
for the variations in flow is very, very
intriguing. The question is, can we really
do that on the fly? We know that what is
happening at the injector will influence
local arterial opacity sometime, perhaps
20 seconds, in the future at least; in some
cases, even more. I am not absolutely certain that there is a way that we can monitor the progression of the injection and
feedback to have any effect on the scan.
But, I do wonder if there are routines that
we might develop to preliminarily test a
persons circulation, to spot-check the
aorta or the popliteal artery. Then we
could use that to come out with the appropriate strategy. But, at this stage, that is a
rather cumbersome thing to do.
Nevertheless, I think it should be our
goal to develop an algorithmic approach
to at least understand these contrast
dynamics. If we do know what these
aortopopliteal transit times are, then
we should understand the optimum way
to deliver contrast for that individual.
LAWLER: It is a very small area and it
is highly selective. So, perhaps, it is not a
major issue for a lot of people. But I do
think the question really arises in cases
such as in the posttraumatic leg that is
hyperemic or perhaps if they are going to
fix an ulcer with a free flap. This is reflected
by the lack of literature below the calf: the
question is: Can I sacrifice this vessel to
make a free flap? I think you would be very
courageous to make that decision when

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you have venous contamination, and you

cannot confidently say that all three vessels running into the foot are clearly open.
RUBIN: It has been our experience
that, even in the setting of venous contamination, we always look at the transverse sections and we believe we can
visualize arterial anatomy in spite of
venous contamination. We have a paper
submitted specifically addressing those
issues. The surgical plan was always in
agreement with what was demonstrated
on imaging, and the outcomes of the
operations were viable at least 3 months
down the line, which suggests that CT
does adequately provide the information.
However, in particular, in acutely traumatized patients in whom there is massive
soft-tissue injury, you can see remarkable
venous opacification, particularly in the
upper extremities. I think there we see
more venous contamination than in the
legs, and it really just requires some diligence to examine the transverse sections
and mentally filter out the veins. As long as
you are paging through, it works pretty
well. But you are right, the volume renderings can be very confusing.
U. JOSEPH SCHOEPF, MD: I
believe the images that you show are
much more impressive than anything
that we have available with MR these
days, for example. But where exactly do
you see CT as opposed to MR in its indication for doing that kind of study?
RUBIN: Right now it is pretty clear
that the rate of voxel acquisition for an
equally sized voxel on CT is far outstripping MR. As I have indicated, we are getting to the point at which CT may be getting too fast and we have to wait for the
bolus anyway. I think MRs great hope
right now is the successful development
of parallel imaging, which is going to require more widespread use of higher
field-strength magnets, like 3T. A high
field-strength magnet will compensate
for the signal-to-noise limitations that
come about from parallel imaging while
allowing for the improved spatial resolution that is possible with parallel imaging.

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Contrast Use in CTA Applications

So, who knows? If there is widespread
deployment of 3T MR scanners or maybe
higher field-strength scanners and successful implementation of parallel imaging, then maybe MR will give images like
this. But at this stage, you are right. We try
to do peripheral MRA as frequently as
possible, but at this stage, CTA is almost
always a better quality study.
SCHOEPF: Also, I was really intrigued by the data that you showed on
hemodynamics in the lower extremity
runoff studies. One of the arguments that
is brought against the use of CT, over
digital subtraction angiography, for
example, is exactly that point, that you
are not able to visualize or assess a phenomenon, such as arterial inflow, to
determine whether the lesion within the
lower runoff is really hemodynamically
significant. Do you believe that some of
those developments might come in
handy to overcome those limitations?
RUBIN: In general, what our vascular
surgeons like to repeatedly remind us is
that they treat patients, not scans; or they
treat patients, not angiograms. Therefore,
they are going to perform bypass on a
patient based on that patients symptoms.
They know that if there appears to be a
high-grade stenosis downstream and
there is a high-grade stenosis upstream,
they need to fix them both. Otherwise,
their graft is ultimately going to be less
viable and potentially thrombose.
So these issues of using the contrast
dynamics in the setting of occlusive disease to lead to treatment have been less
relevant for us. There are situations, such
as in arterial venous fistulae, which obviously are very specialized. In those cases,
the contrast dynamics may be more useful. As we move ahead to 64-row CT
scanners, chances are, we will be able to
park ourselves at the nidus of an arteriovenous malformation and really ob-

July 2004

serve these sorts of phenomena. But I do

not think that comes up very frequently at
this stage.
ELLIOT K. FISHMAN, MD: At
least in my experience with peripheral
imaging of both upper and lower extremities, saline chasers have worked really
well. I think it really helps in terms of getting good homogeneous opacification,
especially of the lower extremities. Do
you have any experience doing that?
RUBIN: Yes. We are using saline
chasers on the dual-chamber injector.
Although, I must say that I do not have a
really good intuition that our opacification is any more homogeneous. Typically,
what it does is prolong the bolus, which
gives us a little more usable bolus.
I am not sure that homogeneous opacification is necessarily what we are after
here in the periphery. In a sense, the proximal vessels are big and the distal vessels
are small and are more susceptible to volume averaging. So, in some respects, I
think it is a good thing that the vessels get
brighter as you go along, because you
have a harder time detecting small vessels
than you do big ones. I am sure that using
a saline chaser is an advantage. It is definitely an advantage to return pooled
contrast in the veins into the central circulation. I think we need more investigation
as to what ultimate impact it has on the
quality of the CTA data set.
FISHMAN: Right, but I think it has
made a very big difference in terms of getting smaller vessels in, say, the legs. We
have been using a 50 mL saline chaser.
That seems to have made a major difference, at least for us.
W. DENNIS FOLEY, MD: Geoff, I
was interested in your different transit
times. You said that it was unrelated to
the patients clinical symptomatology.
RUBIN: Yes, unrelated even to the
severity of their disease.

BRIAN R. HERTS, MD: Was it correlated with heart rate?

RUBIN: It was not correlated with
anything that we measured.
LAWLER: You are filling the tube of
the aorta with so much contrast, and it is a
big elastic artery that is so highly variable. So, before the contrast even gets to
the lower extremities, there is going to be
a massive variation. It will vary even if
you use a constant because of the rate that
ends up feeding into the inflow vessel of
the iliac. Again, it is going around the
whole lungs, as well, before it comes to
the left side. There are so many variables
before you even get there.
RUBIN: There are a tremendous number of variables in terms of the relative
vascular resistance of different major
beds and what percentage of the cardiac
output is being directed to the legs or not.
That is difficult.
FOLEY: You probably have to determine the transit time from the aorta to
the ankle.
RUBIN: But, how are we going to do
that? You notice that I made a big assumption here, which is that it is a constant rate. Dominik measured from the
aorta to the popliteal and I just assumed
that it is the same rate down to the ankle.
I think it is going to be very difficult
because if you just give a 16-mL bolus,
you are not going to be able to see that in
those tiny vessels down there.
So I think it is probably not unreasonable to consider that the aortopopliteal
transit time is very closely linked to the
aortoanterior tibial or dorsalis pedis transit time. I think we are going to have to
begin operating on the assumption that
measuring aortopopliteal and not aortoankle arterial transit times probably
would get us pretty close and just see
what limitations are associated with
those measurements.

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