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Published on: September 22, 2020
Iliac artery calcification score stratifies mortality risk estimation in patients with chronic limb-threatening
Cindy Huynh1, Iris Liu2, Rym El Khoury2
1Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
Insights
Adding common iliac artery calcification scores to the Vascular Quality Initiative (VQI) model improves mortality risk prediction for patients with chronic limb-threatening ischemia (CLTI) undergoing revascularization.
Area of Science:
- Vascular Surgery
- Cardiovascular Imaging
- Health Outcomes Research
Background:
- Patients with chronic limb-threatening ischemia (CLTI) face significant risks of adverse limb outcomes and mortality.
- The Vascular Quality Initiative (VQI) provides a prediction model to estimate mortality risk after revascularization, aiding clinical decisions.
- Improving the accuracy of existing risk calculators is crucial for optimizing patient care.
Purpose of the Study:
- To enhance the discrimination of the 2-year VQI risk calculator for mortality in CLTI patients.
- To investigate the impact of incorporating a common iliac artery (CIA) calcification score, derived from computed tomography (CT) scans, into the VQI model.
- To assess if CIA calcification can further stratify mortality risk in patients initially categorized as low-risk by the VQI model.
Main Methods:
- Retrospective analysis of 131 CLTI patients who underwent infrainguinal revascularization between January 2011 and June 2020.
- Computed tomography scans were used to assess CIA calcification morphology, circumference, and length, generating a total calcium burden (CB) score.
- The VQI CLTI model was applied, and the CB score was analyzed for its association with 2-year mortality, particularly within the low-risk VQI subgroup.
Main Results:
- Higher common iliac artery (CIA) calcification burden was significantly associated with increased mortality in patients undergoing infrainguinal revascularization for CLTI.
- In the low-risk VQI mortality subgroup, patients with severe CIA calcification exhibited a significantly higher risk of mortality (hazard ratio, 2.5).
- The CIA calcification score demonstrated the ability to further stratify mortality risk within the low-risk VQI group (P = .04).
Conclusions:
- Increased common iliac artery calcification is a significant predictor of mortality in patients with chronic limb-threatening ischemia undergoing infrainguinal revascularization.
- Preoperative assessment of CIA calcification can refine perioperative risk stratification.
- Incorporating CIA calcification into risk models may enhance clinical decision-making for CLTI patients.
Objective:
Patients with chronic limb-threatening ischemia (CLTI) are at high risk for adverse limb outcomes and mortality. Using the Vascular Quality Initiative (VQI) prediction model to estimate mortality after revascularization can assist with clinical decision-making. We aimed to improve the discrimination of the 2-year VQI risk calculator by incorporating a common iliac artery (CIA) calcification score based on computed tomography scans.
Methods:
This was a retrospective analysis of patients who underwent infrainguinal revascularization for CLTI from January 2011 to June 2020 and had a computed tomography scan of the abdomen/pelvis 2 years before or up to 6 months after revascularization. CIA calcium morphology, circumference, and length were scored. Bilateral scores were summed for the total calcium burden (CB) score, which was trichotomized (mild, 0-15; moderate, 16-19; severe, 20-22). The VQI CLTI model was used to categorize patients as low, medium, or high risk for mortality.
Results:
A total of 131 patients with a mean age of 69±12 years were included in the study, and 86 (66%) were men. CB scores were mild in 52 (40%), moderate in 26 (20%), and severe in 53 (40%) patients. Older patients (P = .0002) and those with coronary artery disease (P = .06) had higher CB scores. Patients with severe CB scores were more likely to undergo infrainguinal bypass compared with those with mild or moderate CB scores (P = .006). The 2-year VQI mortality risk was calculated to be low in 102 (78%), medium in 23 (18%), and high in 6 (4.6%) patients. In the "low-risk" VQI mortality subgroup, 46 (45%) patients had mild, 18 (18%) had moderate, and 38 (37%) had severe CB scores, and patients with severe CB scores had significantly higher risk of mortality compared with those with mild or moderate scores (hazard ratio, 2.5; 95% confidence interval, 1.2-5.1; P = .01). In this "low-risk" VQI mortality subgroup, CB score further stratified the risk of mortality (P = .04).
Conclusions:
Higher total CIA calcification was significantly associated with mortality in patients undergoing infrainguinal revascularization for CLTI, and preoperative assessment of CIA calcification may help with perioperative risk stratification and guide clinical decision making in this population.
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