Photon-Counting CT Angiography Enables Superior Preoperative Perforator Depiction for Fibular Transplant Surgery Requiring Less Contrast Agent Compared to Energy-Integrating CT

<b>Background/Objectives</b>: The objective of this study was to ascertain whether photon-counting CT angiography (PCD-CTA) can optimize image quality for the visualization of perforating arteries for planning fibular transplant procedures in comparison to energy-integrating CT angiography (EID-CTA). <b>Methods</b>: In this retrospective single-center study, all patients who underwent preoperative CT of the peripheral runoff for planning between October 2021 and July 2023 were consecutively included. PCD-CTA was performed in standard resolution mode as 55 keV images with 90 mL of iodine-containing contrast agent or alternatively, an EID-CTA as a low-kV scan with 110 mL of contrast agent. The raw data were reformatted using comparable soft vascular and sharp regular convolution kernels, slice thickness/increment, and field of view. Contrast-to-noise ratio was calculated for objective image quality. Subjective evaluation was based on a rating by three radiologists using a five-point Likert scale (criteria: overall image quality, luminal attenuation, vessel sharpness, and perforator depiction). <b>Results</b>: Of the 26 patients who were screened, 9 could be included in each group, while 8 were excluded due to incomplete reconstructions. The reduction in contrast agent dose resulted in a non-significant decrease in luminal attenuation on PCD-CTA (452.5 ± 53.6 HU vs. 465.5 ± 99.6 HU; <i>p</i> = 0.375). The image noise was considerably lower for PCD-CTA (21.1 ± 1.0 HU vs. 32.9 ± 1.6 HU; <i>p</i> < 0.001). This resulted in a significantly higher contrast-to-noise ratio (CNR) for sharp kernel reconstructions (22.4 ± 3.5 vs. 14.5 ± 3.8; <i>p</i> < 0.001). No significant differences were observed for the soft vascular kernel. Subjective evaluation revealed a significant enhancement in overall image quality, vascular sharpness, and perforator depiction for PCD-CTA with sharp reconstructions. In contrast, soft kernel reconstructions and luminal attenuation demonstrated no substantial difference. Interrater agreement was good to excellent. <b>Conclusions</b>: PCD-CTA with sharp kernel reformatting has been demonstrated to yield superior image quality and perforator delineation of the fibular artery in comparison to standard EID-CTA.