A systematic review of the association between arterial calcification on preoperative imaging and clinical outcomes in peripheral arterial disease

OBJECTIVE: Peripheral arterial disease may lead to chronic limb-threatening ischemia, which is associated with major amputation and mortality. Early detection of patients at risk for poor outcomes could allow for patient-tailored prevention and treatment strategies, averting these adverse events. Coronary and aortic calcification have previously been shown to predict future cardiovascular events and mortality. The objective of this review was to investigate the association between peripheral artery calcification and clinical outcomes in symptomatic patients with peripheral arterial disease, either in the natural course or after revascularization.

METHODS: A systematic search in PubMed, Embase, and Cochrane CENTRAL up until September 1, 2024, yielded 2963 records. Studies were included if they: (1) were written in English; (2) reported original data; (3) recruited symptomatic patients with peripheral arterial disease (with claudication or chronic limb-threatening ischemia); (4) quantified arterial calcification in the infrarenal aorta and/or distal arteries with a calcium score based on preoperative or alternative noninvasive imaging; and (5) compared clinical outcomes between patients with a range of quantitative or semiquantitative calcification assessments. Risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) method.

RESULTS: A total of 51 studies (N = 10,522 patients) met the inclusion criteria. Twelve studies (n  = 1058) used quantitative scores, 37 used semiquantitative scores (n = 9208), and two used both (n = 256). Mean follow-up of included studies ranged between 6 and 46 months. A clear trend towards a higher rate of major adverse limb events, amputation, major adverse cardiovascular events, and mortality was found with increasing calcium scores. However, relatively low sample sizes and heterogeneity in calcium scoring methods, patient population, and performed interventions warrant cautious interpretation of these results.

CONCLUSION: Further standardization of calcium scoring and follow-up studies in larger cohorts are needed to confirm the observed associations between calcification scores and major adverse events and to facilitate implementation of calcium scoring in clinical practice.