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ARTICLE

Accuracy of Computed Tomographic Angiography and Magnetic Resonance Angiography for Diagnosing Renal Artery Stenosis

G. Boudewijn C. Vasbinder, MD, PhD; Patricia J. Nelemans, MD, PhD; Alfons G.H. Kessels, MD, MSc; Abraham A. Kroon, MD, PhD; Jeffrey H. Maki, MD, PhD; Tim Leiner, MD, PhD; Frederik J.A. Beek, MD, PhD; Michael B.J.M. Korst, MD; Karin Flobbe, PhD; Michiel W. de Haan, MD, PhD; Willem H. van Zwam, MD; Cornelis T. Postma, MD, PhD; M. G. Myriam Hunink, MD, PhD; Peter W. de Leeuw, MD, PhD; Jos M.A. van Engelshoven, MD, PhD, for the Renal Artery Diagnostic Imaging Study in Hypertension (RADISH) Study Group*

2 November 2004 | Volume 141 Issue 9 | Pages 674-682

Background: Timely, accurate detection of renal artery stenosis is important because this disorder may be a potentially curable cause of hypertension and renal impairment.

Objective: To determine the validity of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) compared with digital subtraction angiography (DSA) for detection of renal artery stenosis.

Design: Prospective multicenter comparative study conducted from 1998 to 2001. Two panels of 3 observers judged CTA and MRA image data and were blinded to all other results. Digital subtraction angiography images were evaluated by consensus.

Setting: 3 large teaching hospitals and 3 university hospitals in the Netherlands.

Patients: 402 hypertensive patients with suspected renal artery stenosis were included. A group of 356 patients who underwent all 3 diagnostic tests was used for analysis.

Measurements: Reproducibility was assessed by calculating interobserver agreement. Diagnostic performance was evaluated in terms of sensitivity, specificity, and other diagnostic variables. Atherosclerotic stenoses of 50% or greater and fibromuscular dysplasia were considered clinically relevant.

Results: Twenty percent of patients who underwent all 3 tests had clinically relevant renal artery stenosis. Moderate interobserver agreement was found, with values ranging from 0.59 to 0.64 for CTA and 0.40 to 0.51 for MRA. The combined sensitivity and specificity were 64% (95% CI, 55% to 73%) and 92% (CI, 90% to 95%) for CTA and 62% (CI, 54% to 71%) and 84% (CI, 81% to 87%) for MRA.

Limitations: Eighteen percent of the patients were included nonconsecutively. Digital subtraction angiography may be an imperfect reference test.

Conclusion: Computed tomographic angiography and MRA are not reproducible or sensitive enough to rule out renal artery stenosis in hypertensive patients. Therefore, DSA remains the diagnostic method of choice.

*For a list of the other investigators and research coordinators who participated in RADISH, see the Appendix.

Editors' Notes Context Physicians sometimes use computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) to diagnose renal artery stenosis. Contribution This prospective multicenter study compared CTA and MRA with digital subtraction angiography (the reference standard) in 402 hypertensive patients with suspected renal artery stenosis. Multiple experienced physicians sometimes disagreed about whether the CTA and MRA tests showed renal artery stenosis. The sensitivity estimates of CTA and MRA for detecting renal artery stenosis were 64% and 62%. Implications In this study, even trained physicians had difficulty interpreting some CTA and MRA tests, and neither test was sensitive enough to rule out renal artery stenosis. –The Editors

 

Author and Article Information

From Maastricht University Hospital, Maastricht; University Medical Center St. Radboud, Nijmegen; Jeroen Bosch Medical Center, 's Hertogenbosch; St. Elisabeth Hospital, Tilburg; University Medical Center, Utrecht; and Máxima Medical Center, Veldhoven.

Grant Support: By the Dutch Health Care Insurance Board (OG 97-003).

Potential Financial Conflicts of Interest: Grants received: J.H. Maki (U.S. Department of Veterans Affairs), M.G.M. Hunink (Dutch Health Care Insurance Board).

Requests for Single Reprints: G. Boudewijn C. Vasbinder, MD, PhD, Cardiovascular Research Institute Maastricht (CARIM), Department of Radiology, Maastricht University Hospital, PO Box 5800, NL-6202 AZ Maastricht, the Netherlands; e-mail, vasbinder{at}rad.unimaas.nl.

Current Author Addresses: Drs. Vasbinder, Leiner, Flobbe, de Haan, van Zwam, and van Engelshoven: Cardiovascular Research Institute Maastricht (CARIM), Department of Radiology, Maastricht University Hospital, PO Box 5800, NL-6202 AZ Maastricht, the Netherlands.

Dr. Nelemans: Department of Epidemiology, Maastricht University, P. Debyeplein 1, NL-6229 HA Maastricht, the Netherlands.

Dr. Kessels: Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Hospital, PO Box 5800, NL-6202 AZ Maastricht, the Netherlands.

Drs. Kroon and de Leeuw: Department of Internal Medicine, Maastricht University Hospital, PO Box 5800, NL-6202 AZ Maastricht, the Netherlands.

Dr. Maki: Department of Radiology, Puget Sound Veterans Affairs Health Care System, 1660 South Columbian Way, Seattle, WA 98108-1597.

Dr. Beek: Department of Radiology, University Medical Center Utrecht, PO Box 90000, NL-3509 AA Utrecht, the Netherlands.

Dr. Korst: Department of Radiology, Jeroen Bosch Hospital, PO Box 90153, NL-5200ME 's-Hertogenbosch, the Netherlands.

Dr. Postma: Department of Internal Medicine, University Medical Center St. Radboud, Geert Grooteplein-Zuid 10, NL-6525 GA Nijmegen, the Netherlands.

Dr. Hunink: Department of Epidemiology and Biostatistics, Erasmus Medical Center, Dr. Molewaterplein 40, NL-3015 GD Rotterdam, the Netherlands.

Author Contributions: Conception and design: G.B.C. Vasbinder, P.J. Nelemans, A.G.H. Kessels, A.A. Kroon, K. Flobbe, M.W. de Haan, M.G.M. Hunink, P.W. de Leeuw, J.M.A. van Engelshoven.

Analysis and interpretation of the data: G.B.C. Vasbinder, P.J. Nelemans, A.G.H. Kessels, A.A. Kroon, J.H. Maki, T. Leiner, F.J.A. Beek, M.B.J.M. Korst, K. Flobbe, M.W. de Haan, W.H. van Zwam, M.G.M. Hunink, P.W. de Leeuw, J.M.A. van Engelshoven.

Drafting of the article: G.B.C. Vasbinder, P.J. Nelemans, A.G.H. Kessels, A.A. Kroon, J.H. Maki, T. Leiner.

Critical revision of the article for important intellectual content: G.B.C. Vasbinder, P.J. Nelemans, A.G.H. Kessels, A.A. Kroon, J.H. Maki, T. Leiner, F.J.A. Beek, M.B.J.M. Korst, M.W. de Haan, W.H. van Zwam, C.T. Postma, M.G.M. Hunink, P.W. de Leeuw, J.M.A. van Engelshoven.

Final approval of the article: G.B.C. Vasbinder, P.J. Nelemans, A.G.H. Kessels, A.A. Kroon, J.H. Maki, T. Leiner, F.J.A. Beek, M.B.J.M. Korst, K. Flobbe, M.W. de Haan, W.H. van Zwam, C.T. Postma, M.G.M. Hunink, P.W. de Leeuw, J.M.A. van Engelshoven.

Provision of study materials or patients: G.B.C. Vasbinder, P.J. Nelemans, A.A. Kroon, M.W. de Haan, C.T. Postma, P.W. de Leeuw, J.M.A. van Engelshoven.

Statistical expertise: P.J. Nelemans, A.G.H. Kessels.

Obtaining of funding: P.J. Nelemans, A.G.H. Kessels, P.W. de Leeuw, J.M.A. van Engelshoven.

Administrative, technical, or logistic support: G.B.C. Vasbinder, T. Leiner, K. Flobbe.

Collection and assembly of data: G.B.C. Vasbinder, T. Leiner, K. Flobbe, P.W. de Leeuw.

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