Endovascular treatment of severely calcified aortoiliac occlusive disease: long-term outcomes from a single-centre cohort

Summary: Background: To evaluate safety, technical success, and long-term outcomes of endovascular therapy (EVT) in severely calcified aortoiliac occlusive disease (AIOD), focusing on lesion characteristics and the presence of coral reef aorta (CRA). Patients and methods: This single-center retrospective study included 216 patients with angiographically confirmed calcified abdominal aortic stenosis (mean PACSS 3.7 ± 0.8) treated with EVT between 2005 and 2023. Of these, 33 patients had coral reef aorta (CRA). Patients were stratified by lesion location and CRA presence. Primary endpoints were 30-day adverse events and technical success (residual stenosis <30%). Secondary endpoints were major adverse cardiovascular events (MACE), major adverse limb events (MALE), and all-cause mortality. Cox regression identified predictors of outcome. Results: Technical success was achieved in 81.9%. Thirty-day mortality was 0.5%. At 10 years, freedom from MACE was significantly lower in patients with non-bifurcation abdominal aortic stenosis (56% vs. 76%; aHR 2.13, p < .05) and lowest in CRA (30% vs. 71%; aHR 3.17, p < .05). Independent predictors of MACE were CRA, chronic total occlusion (aHR 3.38, 95% CI 1.57–7.29), critical limb-threatening ischemia (aHR 3.67, 95% CI 1.74–7.75), and age (aHR 1.06 per year, 95% CI 1.01–1.11). MALE was more frequent in patients with peripheral arterial disease (aHR 2.07, 95% CI 1.12–3.81), CRA (aHR 2.51, 95% CI 1.17–5.40), and current smokers (aHR 5.10, 95% CI 1.23–21.0). Conclusions: CRA and non-bifurcation abdominal aortic stenosis are associated with reduced long-term freedom from MACE after EVT. These findings define high-risk subgroups within calcified AIOD and highlight the prognostic value of anatomical lesion characteristics for treatment planning and follow-up.