Computed tomography image quality with high-flow contrast via high-pressure central venous catheter in critically ill patients

Abstract

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Contrast-enhanced computed tomography (CECT) is a key diagnostic procedure in critically ill patients, in whom contrast media (CM) is injected most of the time through central venous catheter (CVC). The quality of contrast enhancement relies on patient-dependent (cardiac output, weight and size) or patient-independent (technology of CT-scan, type of catheter, site of injection, CM volume, and injection rate) factors [1]. Injection rate is a crucial parameter of contrast enhancement, but is limited by the intrinsic quality of the venous access, with risks of displacement, ballooning, rupture and contrast extravasation in case of high-pressure (HP) or high-flow rate [2]. While standard CVC allow injection rate up to 5 mL/sec, manufacturers do not recommend to use them for pressure injection [3]. Thus, CVCs allowing higher pressures and flow rates have been recently designed [4]. This could improve the image quality of CECT, or reduce CM volume for similar quality, thereby reducing the risk of contrast-induced acute kidney injury and minimizing environmental impact. However, the interest of CM injection at high-flow through HP CVC has never been investigated. Here we report on the objective image quality of CECT images obtained with CM injected at high-flow rate through HP CVC versus standard flow rates through standard CVC. All critically ill adult patients with superior vena cava CVC requiring thoracic and/or abdominal CECT were analyzed. Before September 2023 (retrospective/before period), standard CVC were used (references: CV-12703, CV-15703, CV-12854, CV-15854, Arrow^®/Teleflex^®). After September 2023 (prospective/after period), HP CVC were used (references: EU-42854-HPS, EU-45854-HPS, Arrow^®/Teleflex^®). Patients on ECMO or requiring isolated head CT-scan were excluded. Except flow rate, all CT-scans with CM injection were performed according to the same protocol. CM injection was performed with the device Bracco Injeneering SA^® (650197 CT Expres™ - Control Panel). Monoergenetic CT acquisitions were performed with CT device (Revolution CT Apex Elite, General Electric Medical Systems^®). The injection sequence was 10 mL of isotonic saline, CM injection with volume set at 1 mL/kg, and purge of 20 mL of isotonic saline at the same flow rate. In the standard CVC group, the flow rate was set of 3.5 mL/s, with injection through the 16-gauge distal lumen; in the HP CVC group, the flow rate was set at 10 mL/s, with injection through the dedicated 14-gauge medial lumen. Image quality was assessed based on combination of aortic and liver Signal-to-Noise Ratio (SNR) and Contrast-to-Noise Ratio (CNR) at arterial and portal time at the level of coeliac trunk in aorta and in liver, with blind analysis by a senior radiologist. Briefly, the SNR quantifies the strength of a signal relative to the background noise. It is calculated by dividing the mean signal intensity by the standard deviation of the noise in a round region of interest of 3cm². A higher SNR indicates a clearer and more distinct signal [5]. The CNR measures the contrast between the signal of interest and the background, relative to the noise. It is determined by dividing the difference in signal intensity between a 3cm² round region of interest and a reference region, such as muscle, by the standard deviation of the noise. In this study, noise was air. A higher CNR indicates a better contrast [5]. During the two periods, a total of 75 patients were included: 56 patients had 67 CECT with standard CVC and 19 patients had 31 CECT with HP CVC. Table 1 displays main characteristics of patients, factors influencing cardiac output, and CECT. There was no clinically relevant difference between the groups. Flow rate was significantly higher in the HP CVC group, with a median flow rate of 7.7 mL/s [7- 8.3] compared to 3.5 mL/s in the standard CVC group (p < 0.001). Volume of CM or iodine dose normalized to body weight were similar. However, there were no significant differences in aortic and liver SNR and CNR measurements during the arterial and portal phases. This preliminary report, as the first series evaluating the image quality of CECT with high-flow CM injection via HP CVCs to enhance, deserves some limitations. Firstly, the theoretical flow rate of 10 ml/s was not achieved, with an effective median flow rate of 7.7 mL/s. Possible explanations are limits of calibration of the power injector, or changes in the CM viscosity, which depends on the ambient room temperature which could have varied over time. Secondly, we estimated a flow rate of 3.5 mL/s in the standard CVC group because this information could not be retrieved retrospectively. However, the exact flow rates remain unknown in both groups. Finally, the delay between CM injection and image acquisition was unchanged whatever the CM injection flow rate, but acquisition timing might be adjusted accordingly [1]. To conclude, in this series focusing on critically ill patients, the use of HP CVC allowed high-flow injection of CM without any adverse events. However, this strategy was not associated with improved objective image quality. Further studies are needed in specific populations, particularly those with cardiac output modifications in whom CECT quality is often reduced (such as patients on ECMO, with sickle cell disease, or pregnancy), or indications (research of pulmonary embolism or CT coronary angiogram).

Table 1 Baseline characteristics

Full size table

Data are available on reasonable request to the corresponding author.

CECT:

Contrast-enhanced computed tomography

CM:

Contrast media

CNR:

Contrast-to-noise ratio

CT:

Computed tomography

CVC:

Central venous catheter

ECMO:

ExtraCorporeal Membrane Oxygenation

HP:

High-pressure

ICU:

Intensive care unit

SNR:

Signal-to-noise ratio

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The authors received no financial support for the study or publication. Teleflex provided the high pressure central venous catheters for the “after period” study at no charge. However, the company was not involved in the protocol development, data collection, analysis and had no access to data. Interpretation and manuscript writing were performed only by the authors.

Authors and Affiliations

1. Service d’anesthésie-réanimation et médecine péri-opératoire, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, F-94010, France

   Emmanuelle Gentil, Quentin de Roux, Solène Ribot, Lucien Lapeyre, Victor PalombI, Christophe Quesnel & Nicolas Mongardon

2. Service d’imagerie médicale, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, F-94010, France

   Alain Luciani & Vania Tacher

3. Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France

   Quentin de Roux & Nicolas Mongardon

4. Ecole Nationale Vétérinaire d’Alfort, IMRB, Maisons-Alfort, F-94700, France

   Quentin de Roux & Nicolas Mongardon

5. Faculté de Santé, Université Paris Est Créteil, Créteil, F-94010, France

   Quentin de Roux, Alain Luciani, Christophe Quesnel, Vania Tacher & Nicolas Mongardon

6. GRCT OPTIMA, Université Paris Est Créteil, Créteil, F-94010, France

   Quentin de Roux, Christophe Quesnel & Nicolas Mongardon

Authors

1. Emmanuelle GentilView author publications

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2. Quentin de RouxView author publications

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3. Solène RibotView author publications

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4. Lucien LapeyreView author publications

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5. Victor PalombIView author publications

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6. Alain LucianiView author publications

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7. Christophe QuesnelView author publications

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8. Vania TacherView author publications

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9. Nicolas MongardonView author publications

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Contributions

EG, VT and NM designed the study and wrote the manuscript. EG, QDR, LL, VP, VT and NM collected study data. EG, VT and NM performed the statistical analysis. All authors participated in writing and revising the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nicolas Mongardon.

Ethics approval and consent to participate

Patients were informed of the anonymous data extraction and analysis from medical charts. This study was approved by the Comité d’Ethique pour la Recherche en Anesthésie-Réanimation (CERAR, IRB 00010254-2023-117).

Consent for publication

All authors have given their consents for publication.

Competing interests

NM serves as a consultant for AOP Health and Baxter. The other authors have not disclosedany potential competing interests.

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Gentil, E., de Roux, Q., Ribot, S. et al. Computed tomography image quality with high-flow contrast via high-pressure central venous catheter in critically ill patients. Crit Care 29, 433 (2025). https://doi.org/10.1186/s13054-025-05673-4

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• Received: 31 August 2025

• Accepted: 18 September 2025

• Published: 14 October 2025

• DOI: https://doi.org/10.1186/s13054-025-05673-4

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