LETTER TO THE EDITOR
Arms Down Cone Beam CT Hepatic Angiography: Are We
Focusing on the Wrong Target?
Gianluca De Rubeis
Received: 21 February 2018 / Accepted: 28 March 2018 / Published online: 12 April 2018
Ó Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe
We read with great interest the recent article by Dr.
Gonzalez-Aguirre and colleagues entitled ‘‘Arms Down
Cone Beam CT Hepatic Angiography Performance
Assessment: Vascular Imaging Quality and Imaging Arte-
facts’’ . One of the most important advantages of cone
beam CT (CBCT) is the possibility to evaluate the lesion’s
feeders assisting their identiﬁcation and catheterization .
In this set, the patient’s arms positioning is crucial in order
not to impair CBCT imaging. Dr. Gonzalez-Aguirre et al.
had elegantly demonstrated that vessels’ visualization is
independent from the patient’s arms position, allowing to
perform the entire procedure without patient’s movements.
This minimizes the risk of contamination and reduces
However, literature shows that the major pivotal strength
of CBCT, either mono-phasic or possibly bi-phasic, is the
ability to depict in intra-procedurally ‘‘occult lesions’’, not
visible at pre-procedural second-line non-invasive imaging
(MRI, MDCT) . This ability is not just for show, but yield
to some major clinical implications: the visualization of an
occult nodule identiﬁes a subset of population experiencing
fast tumour growth, having consequences on the number of
adjunctive treatments controlling tumour growth (adjunctive
RFA, or TACE procedures) and prioritization for trans-
plantation . Moreover, bi-phasic CBCT, with its unique
ability to intra-procedural permit nodule characterization,
could help in patients’ reclassiﬁcation and real-time TACE
strategy modiﬁcation .
In this light would be a crucial interest for the audience
to know whether the CBCT acquisition with arms down
does not alter the diagnostic performance of the modality
and ability of lesion’s characterization, especially for those
lesion localized peripherally, where the beam hardening
artefacts have been shown to be signiﬁcant.
Finally, patient’s positioning is fundamental for CBCT
imaging. By acquiring the scan with patient’s arm down,
liver volume would not be located within the rotation iso-
centre. This could be a substantial limitation for lesion
located within the left liver lobe, eventually hypertrophied,
and for high BMI patients.
Compliance with Ethical Standards
Conﬂict of interest All authors declare that they have no conﬂict of
Ethical Approval Statement All procedures performed in studies
involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and
& Pierleone Lucatelli
Gianluca De Rubeis
Vascular and Interventional Radiology Unit, Department of
Radiological, Oncological and Anatomo-Pathological
Sciences, ‘‘Sapienza’’ University of Rome, Viale del
Policlinico, 155, 00161 Rome, Italy
Department of Diagnostic and Interventional Radiology,
University Campus Bio-Medico of Rome, Via A
Portillo, 21, Rome, Italy
Cardiovasc Intervent Radiol (2018) 41:1134–1135