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Objectives: To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg. Design: Randomised controlled diagnostic trial. Materials and methods: Patients were randomly allocated to MRA (n =97) or DSA (n =100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs. Results: A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p =0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p =0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were €4768,- in the MRA group compared to €4697,- in the DSA group (95% CI of difference −1331;1472). Conclusions: In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable. [Copyright &y& Elsevier]