Abstract
INTRODUCTION: Extensive lower limb arterial calcification complicates revascularization and is linked to poor outcomes, including limb loss and cardiovascular events. Standardized scoring systems are lacking, particularly in aortoiliac TASC II D lesions. This study evaluated the prognostic value of a CT-based Iliac Calcium Score (ICS) in predicting major adverse limb events (MALE), cardiovascular events (MACE), and all-cause mortality in patients with severe aortoiliac disease. METHODS: In this prospective cohort (2013-2024), 109 patients with TASC II D aortoiliac occlusive disease underwent elective revascularization and preoperative CT angiography. Iliac artery calcification was scored semiquantitatively by morphology, circumference, and lesion length. Patients were stratified into low (≤ 36) and high (≥ 37) ICS groups. Outcomes included MALE, MACE, and mortality, analyzed using Kaplan-Meier and Cox regression. RESULTS: The study included 109 patients (95.4% male) with a median follow-up of 67 months. Baseline characteristics were similar across ICS groups, though ICS ≥ 37 was associated with more advanced Rutherford stages (p = 0.035). At 30 days, both groups improved clinically, but Rutherford class improvement was greater in the ICS ≤ 36 group (p = 0.013), with no other significant differences. At 1 year, MALE was more frequent in patients with ICS ≥ 37 (48.1% vs. 27.3%; p = 0.024). At 60 months, this group showed significantly lower amputation-free (74.5% vs. 97.8%; p = 0.002), MACE-free (47.3% vs. 73.4%; p = 0.005), and overall survival (54.6% vs. 77.0%; p = 0.013). Acute heart failure occurred only in the high ICS group (p = 0.015), while patency rates were similar. ICS ≥ 37 remained an independent predictor of MACE (aHR 2.30; p = 0.008) and major amputation (aHR 7.52; p = 0.008) in multivariable analysis. CONCLUSION: In patients with extensive TASC II D aortoiliac occlusive disease, an ICS ≥ 37 was independently associated with increased long-term risk of MACE, MALE, and reduced overall survival, despite similar short-term outcomes. These findings support the integration of preoperative calcium scoring as a simple, lesion-specific tool for risk stratification, procedural planning, and personalized postoperative surveillance in complex peripheral arterial disease.