Abstract
Background
The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are
commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable
in the presence of calcified vessels.In this study, we aimed to demonstrate the utility
of lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease
burden and predicting the risk of amputation in patients with PAD.
Methods/Results
Patients who were evaluated in the vascular surgery clinic at Emory University for
PAD and who underwent non-contrast CT of the aorta and lower extremities were included
in the study. Aorto-iliac, femoral-popliteal, and tibial calcium scores were measured
using the Agatston method. ABI and TBI that were obtained within 6 months of the CT
scan were noted and divided into categories of PAD severity. Associations between
ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate
ordinal regression analysis were performed to predict the outcome of amputation. ROC
analysis was performed to compare LECS with other variables in its ability to predict
amputation.
Results
50 patients included in the study cohort were divided into LECS quartiles, with 12-13
patients in each quartile. The highest quartile tended to be older (p=0.016), had
higher percentage of diabetics (p=0.034), and higher frequency of major amputation
(p=0.004) compared to the other quartiles. Patients in the highest quartile of tibial
calcium score were more likely to have stage 3 CKD or greater (p=0.011) and also had
a higher frequency of amputation (p<0.005) and mortality (p=0.041). We found no significant
association between each anatomic LECS and ABI/TBI categories. On univariate analysis,
CKD (OR 12.92 [95% CI 2.01-82.83], p=0.007), DM (OR 5.47 [95% CI 1.27-23.64], p=0.023),
tibial calcium score (OR 6.62 [95% CI 1.79-24.54], p=0.005) and total bilateral calcium
score (OR 6.32 [95% CI 1.18-33.78], p=0.031) were associated with increased risk of
amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score
were identified as important predictors of amputation with HLD and CKD increasing
the overall prediction of the model. On ROC analysis, the addition of tibial calcium
score (AUC 0.94, SE 0.048). significantly improved the prediction of amputation compared
to HLD, CKD and TBI alone (AUC 0.82, SE0.071, p=0.022).
Conclusions
The addition of tibial calcium score to other known PAD risk factors may improve the
prediction of amputation in patients with PAD.
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Article info
Publication history
Accepted:
February 7,
2023
Received in revised form:
January 4,
2023
Received:
November 22,
2021
Publication stage
In Press Journal Pre-ProofFootnotes
Author conflict of interest: none.
Identification
Copyright
Published by Elsevier Inc.
