van Helvoort-Postulart D et al. (2007) Renal artery stenosis: cost-effectiveness of diagnosis and treatment. Radiology 244: 505–513

Researchers have used a decision analytic model to evaluate the costs, benefits and cost-effectiveness ratios of five strategies for the diagnosis and management of renal artery stenosis (RAS): digital subtraction angiography (DSA; comprising diagnostic DSA and subsequent revascularization on a different day); magnetic resonance angiography (revascularization scheduled if scan results positive); CT angiography (revascularization scheduled if scan results positive); immediate tentative percutaneous revascularization (every patient with suspected RAS referred for percutaneous revascularization, with diagnostic DSA immediately before the procedure to determine whether it should go ahead); and medical therapy (antihypertensive medication, without diagnostic imaging or revascularization). Data were extracted from the Netherlands-based Renal Artery Diagnostic Imaging Study in Hypertension (RADISH) and published literature.

For a 50-year-old male with diastolic blood pressure >95 mmHg and at least one clinical sign of renovascular hypertension, the immediate tentative revascularization strategy cost the least (€54,415) and was the most effective (yielding 12.265 quality-adjusted life years [QALYs]); the authors recommend this strategy in all males with suspected RAS. This strategy cost more and yielded more QALYs in a 50-year-old female with the same characteristics, but the incremental cost-effectiveness ratio when compared with DSA was €7,143 per QALY, a figure the group believes is generally acceptable.

Use of a more invasive diagnostic technique became more justified as the probability of RAS increased. Whereas immediate tentative revascularization is cost-effective in patients with high suspicion for renovascular hypertension, in patients at low risk, and in those in whom RAS is unlikely, CT angiography and medical therapy, respectively, seem to be cost-effective.