The Role of Aortic Calcification in the Development and Progression of Aortic Disease: A Narrative Review

Aortic calcification (AC) is increasingly recognized in cardiovascular research, but its clinical significance in aortic aneurysm (AA) and aortic dissection (AD) remains underappreciated. This review synthesizes evidence on AC across aortic segments, its relationship with abdominal and thoracic aortic disease, methods to quantify AC, and potential pathogenic mechanisms. We performed a comprehensive literature review of clinical studies addressing abdominal AC and thoracic AC in relation to abdominal AA, thoracic AA, and thoracic AD, critically evaluating imaging-based assessment techniques including computed tomography-derived scoring systems and volumetric measurements, and summarizing mechanistic data. AC is associated with increased abdominal AA growth rates, higher rupture risk, and worse outcomes after surgical or endovascular repair. Evidence for thoracic AC contributing to thoracic AA progression and thoracic AD incidence is less definitive but suggests a possible role. Computed tomography-based metrics (Agatston score, calcification volume, and calcification index) predominate for AC assessment, though methodological heterogeneity limits comparability across studies. Mechanistically, AC may promote aortic disease via altered aortic morphology, biomechanical impairment (increased stiffness and wall-stress mismatch), and medial degeneration driven by vascular smooth muscle cell osteogenic transformation. These findings identify AC as a key but often underestimated factor in aortic disease. Standardization of imaging protocols and measurement criteria is needed to improve risk stratification, and further research into AC mechanisms and clinical effects could inform management and decision-making for AA and AD.