Ultra-low dose chest CT for the diagnosis of pulmonary arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia

The purpose of this study was to compare ultra-low dose (ULD) and standard low-dose (SLD) chest computed tomography (CT) in terms of radiation exposure, image quality and diagnostic value for diagnosing pulmonary arteriovenous malformation (AVM) in patients with hereditary hemorrhagic telangiectasia (HHT). In this prospective board-approved study consecutive patients with HHT referred to a reference center for screening and/or follow-up chest CT examination were prospectively included from December 2020 to January 2022. Patients underwent two consecutive non-contrast chest CTs without dose modulation (i.e., one ULD protocol 80 kVp or 100 kVp, CTDIvol of 0.3 mGy or 0.6 mGy and one SLD protocol 140 kVp, CTDIvol of 1.3 mGy). Objective image noises measured at the level of tracheal carina were compared between the two protocols. Overall image quality and diagnostic confidence were scored on a 4-point Likert scale (1 = insufficient to 4 = excellent). Sensitivity, specificity, positive predictive value and negative predictive value of ULD CT for diagnosing pulmonary AVM with a feeding artery of over 2 mm in diameter were calculated along with their 95% confidence intervals (CI) using SLD images as the standard of reference. A total of 44 consecutive patients with HHT (31 women; mean age, 42 ± 16 standard deviation (SD) years; body mass index, 23.2 ± 4.5 SD kg/m2) were included. Thirty-four pulmonary AVMs with a feeding artery of over 2 mm in diameter were found with SLD images versus 35 with ULD images. Sensitivity, specificity, predictive positive value, and predictive negative value of ULD CT for the diagnosis of PAVM were 100% (34/34; 95% CI: 90–100), 96% (18/19; 95% CI: 74–100), 97% (34/35; 95% CI: 85–100) and 100% (18/18; 95% CI: 81–100), respectively. A significant difference in diagnostic confidence scores was found between ULD (3.8 ± 0.4 SD) and SLD (3.9 ± 0.1 SD) CT images (P = 0.03). No differences in overall image quality scores were found between ULD CT examinations (3.9 ± 0.2 SD) and SLD (4 ± 0 SD) CT examinations (P = 0.77). Effective radiation dose decreased significantly by 78.8% with ULD protocol, with no significant differences in noise values between ULD CT images (16.7 ± 5.0 SD HU) and SLD images (17.7 ± 6.6 SD HU) (P = 0.07). ULD chest CT provides 100% sensitivity and 96% specificity for the diagnosis of treatable pulmonary AVM with a feeding artery of over 2 mm in diameter, leading to a 78.8% dose-saving compared with a standard low-dose protocol.