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

  1. G. Boudewijn C. Vasbinder, MD, PhD;
  2. Patricia J. Nelemans, MD, PhD;
  3. Alfons G.H. Kessels, MD, MSc;
  4. Abraham A. Kroon, MD, PhD;
  5. Jeffrey H. Maki, MD, PhD;
  6. Tim Leiner, MD, PhD;
  7. Frederik J.A. Beek, MD, PhD;
  8. Michael B.J.M. Korst, MD;
  9. Karin Flobbe, PhD;
  10. Michiel W. de Haan, MD, PhD;
  11. Willem H. van Zwam, MD;
  12. Cornelis T. Postma, MD, PhD;
  13. M. G. Myriam Hunink, MD, PhD;
  14. Peter W. de Leeuw, MD, PhD;
  15. Jos M.A. van Engelshoven, MD, PhD; and
  16. for the Renal Artery Diagnostic Imaging Study in Hypertension (RADISH) Study Group*
  1. 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.

    Abstract

    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 κ 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.

    Article and Author Information

    • 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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    1. Ann Intern Med November 2, 2004 vol. 141 no. 9 674-682
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