The association of aortic and iliac calcification with aortic events, peripheral revascularization and amputation: a DANCAVAS substudy

Introduction While calcification of the thoracic aorta is associated with stroke and myocardial infarction, less is known about the association of aortic and iliac artery calcification with aortic events, peripheral revascularization and amputation (Major Adverse Limb Event, MALE). The aim of this study was to investigate the association between aortic and peripheral artery calcification and the risk of aortic events (aortic dissection, rupture, and surgery) and MALE. Methods This prospective cohort study included all screened participants from the Danish Cardiovascular Screening trial (DANCAVAS). At baseline, all participants underwent comprehensive cardiovascular risk assessments, including full aortic CT-scans measuring aortic and iliac artery calcification. Furthermore, participants completed a baseline questionnaire regarding age, smoking status, medication, and prior diseases. Follow-up data on events were obtained from the Danish Health Registries. The risk period started at the date of inclusion and ended at date of event or end of follow-up on 9th January 2025. The data were evaluated using a competing risk hazard regression adjusted for age, sex, smoking status, BMI, aortic diameter, hereditary predisposition and classical cardiovascular risk factors. Calcifications in the ascending aorta, aortic arch, descending aorta, suprarenal aorta, infrarenal aorta, and the iliac arteries were analysed separately. The outcomes of this study were aortic events (aortic dissection, aneurysm rupture, aneurysm surgery) and MALE, and each segment was analysed for both outcomes, with the participants divided into four groups based on calcification scores. Results In total 15,003 participants underwent screening (95% male, median age 67 years (SD 4), with a median follow-up of 7.7 years (SD 1.7). The analysis of aortic events showed a significant association with calcification scores in the 4th quartile for the aortic arch and descending aorta (HR = 2.02 (95% CI 1.06:3.85), HR = 2.53 (95% CI 1.31:4.89), respectively). The same was true for the iliac calcification score in the 4th quartile (HR = 3.76 (95% CI 1.63:8.71)). There was no association between aortic events and calcification scores in the ascending aorta and abdominal aorta. A much stronger association was found regarding MALE events and calcification scores. Having a calcification score in the 4th group of the ascending aorta (HR = 3.07 (95% CI 2.18:4.32)) or being in the 3rd or 4th quartiles in all remaining segments were significantly associated with an increased hazard ratio for a MALE event. Conclusion In predominantly males aged 60-75 years, higher levels of aortic and iliac calcification were linked to increased hazard ratio for the outcomes, aortic events and MALE. This suggests that calcification of the aorta and iliac arteries should be considered a significant risk factor.Hazard ratios (95% CI) per event group