Aortic and Iliac Calcifications as Predictors of Aortic Dissection, Aneurysm Rupture, and Peripheral Vascular Disease: A Prospective Cohort Study from the DANCAVAS Trials

BACKGROUND: There is limited evidence of the relationship between aortic and iliac calcification and aortic events (aortic dissection or aneurysm rupture) and major adverse limb events (MALEs; peripheral revascularization and lower limb amputation). The aim of this population-based prospective cohort study was to investigate the association of aortic and iliac calcifications with aortic events and MALEs. METHODS: All participants from the DANCAVAS (Danish Cardiovascular Screening) trials who received a full thoracoabdominal aortic computed tomography scan with recorded measurements of aortic and iliac calcification were included. The aorta and iliac artery calcifications were measured in a 5-segment model and categorized into quartiles, apart from the ascending aorta, which was categorized into 4 exposure groups, as the majority of participants had no calcification in the ascending aorta. The participants were followed from inclusion in the DANCAVAS trial until aortic events, MALE, death, or end of follow-up on May 1, 2025. We used a competing risk hazard regression model adjusted for demographics, cardiovascular risk factors, aortic diameter, and ankle-brachial index. RESULTS: In total, 13 065 participants were included in this study (94% men; mean age, 67±4 years). Participants were followed for a mean of 8 years, during which 42 experienced an aortic event, and 311 experienced a MALE. The analyses of the aortic event outcome showed significantly increased subdistribution hazard ratios (SHRs) when having calcification scores in the fourth group or quartile for the ascending and abdominal aorta (SHR, 3.06 [95% CI, 1.15-8.16]; SHR, 7.61 [95% CI, 1.44-40.22], respectively). Calcification scores in the fourth group or quartile were strongly associated with MALEs in all segments: ascending aorta (SHR, 2.20 (95% CI, 1.56-3.10]), aortic arch (SHR, 6.49 [95% CI, 3.10-13.56]), descending aorta (SHR, 2.43; [95% CI, 1.45-4.08]), abdominal aorta (SHR, 7.89 [2.95-21.15]), and iliac arteries (SHR, 13.52 [95% CI, 4.32-42.24]). CONCLUSIONS: Severe aortic and iliac calcification was associated with significantly higher risk of aortic events and MALEs, suggesting that quantifying aortic calcification may provide valuable prognostic information and potentially improve the risk stratification in patients with aortic aneurysm or peripheral artery disease.