Aortoiliac Calcification Research Articles

46. Is MIS-ATP lumbosacral fusion safe in patients with aortoiliac calcification?

46. Is MIS-ATP lumbosacral fusion safe in patients with aortoiliac calcification?

Objective Methods to Assess Aorto-Iliac Calcifications: A Systematic Review.

Vascular calcifications in aorto-iliac arteries are emerging as crucial risk factors for cardiovascular diseases (CVDs) with profound clinical implications. This systematic review, following PRISMA guidelines, investigated methodologies for measuring these calcifications and explored their correlation with CVDs and clinical outcomes. Out of 698 publications, 11 studies met the inclusion criteria. In total, 7 studies utilized manual methods, while 4 studies utilized automated technologies, including artificial intelligence and deep learning for image analyses. Age, systolic blood pressure, serum calcium, and lipoprotein(a) levels were found to be independent risk factors for aortic calcification. Mortality from CVDs was correlated with abdominal aorta calcification. Patients requiring reintervention after endovascular recanalization exhibited a significantly higher volume of calcification in their iliac arteries. Conclusions: This review reveals a diverse landscape of measurement methods for aorto-iliac calcifications; however, they lack a standardized reproducibility assessment. Automatic methods employing artificial intelligence appear to offer broader applicability and are less time-consuming. Assessment of calcium scoring could be routinely employed during preoperative workups for risk stratification and detailed surgical planning. Additionally, its correlation with clinical outcomes could be useful in predicting the risk of reinterventions and amputations.

Aortobifemoral Bypass in Kidney Transplant Candidates: A Ten-Year Experience.

In patients with severe aorto-iliac calcifications, vascular reconstructions can be performed in order to allow kidney transplantation. The aim of this study was to analyze the outcomes of kidney transplant candidates who underwent an aortobifemoral bypass (ABFB) for aorto-iliac calcifications. A retrospective study including all kidney transplant candidates who underwent an ABFB between 2012 and 2022 was performed. Primary outcome was 30-day morbidity-mortality after ABFB. Secondary outcome was accessibility to kidney transplant waiting list. Twenty-two ABFBs were performed: 10 ABFBs in asymptomatic patients presenting severe aorto-iliac circumferential calcifications without hemodynamic consequences, and 12 ABFBs in symptomatic patients in whom aorto-iliac calcifications were responsible for claudication or critical limb threatening ischemia. Overall 30-day mortality was 0%. Overall 30-day morbidity was 22.7%: 1 femoral hematoma and 1 retroperitoneal hematoma requiring surgical drainage in the asymptomatic group, and 2 digestive ischemia requiring bowel resection and 1 femoral hematoma requiring surgical drainage in the symptomatic group. Among the 22 patients, 20 patients could access to kidney waiting list and 8 patients underwent a kidney transplantation, including 3 living-donor transplantations. Aorto-iliac revascularization can be an option to overcome severe calcifications contraindicating kidney transplantation.

Correlation between C-reactive protein to albumin ratio and restenosis after femoral popliteal stenting in patients with lower extremity arteriosclerotic obliterans

Objective: To investigate the study of the correlation between C-reactive protein to albumin ratio (CAR) and restenosis after stenting in patients with lower extremity atherosclerotic occlusive disease(LEASO). Methods: The clinical data of 95 patients with LEASO admitted to the Department of Vascular Surgery of Nanjing Drum Tower Hospital from June 2020 to December 2022 were retrospectively analyzed. There were 67 males and 28 females,aged (73.1±9.4) years (range:51 to 92 years). The patients were classified into the restenosis group (n=61) and the patency group (n=34) according to the CT angiography results. Independent sample t test,Mann-Whitney U test and χ2 test were used to compare the data between two groups. Risk factors for restenosis after femoropopliteal artery stenting in patients with LEASO were analyzed using multivariate Cox regression. The relationship between preoperative CAR level and restenosis after stent placement was analyzed. Subject operating characteristic(ROC) curves of CAR were plotted to assess the predictive value of CAR for restenosis after stenting,and the results were expressed as area under the curve (AUC). Results: The aortoiliac calcification grade,number of stents,length of stents,C-reactive protein and CAR levels in restenosis group were higher than those in the patency group,and the serum albumin level was lower than that in the patency group(all P<0.05). And the results of multifactorial Cox regression analysis showed that higher pre-procedure CAR level and lower ABI value was an independent risk factor for in-stent restenosis. The AUC of the ROC curve for restenosis was 0.737(95%CI:0.617 to 0.856),the AUC of the ROC curve for 12-month restenosis was 0.709(95%CI:0.602 to 0.815), and the AUC of the ROC curve for 24-month restenosis was 0.702(95%CI:0.594 to 0.811). Conclusion: Higher pre-procedural CAR levels in patients with LEASO is risk factor for in-stent restenosis,and CAR has a predictive value for restenosis after lower extremity arterial stent dilatation and angioplasty.

Hybrid Clampless Anastomosis in Antegrade Aorto-Superior Mesenteric Artery Bypass.

Bypass surgery in severe aorto-iliac calcifications is a complex procedure. Aortic clamping can be highly risky and endovascular approach can be unsuccessful. We report our experience describing three cases of chronic mesenteric ischemia. In all three cases the preoperative computed tomography angiography revealed an ostial occlusion of the celiac trunk and of the superior mesenteric artery (SMA), a coral reef abdominal aorta, and severe calcification of the iliac arteries. An antegrade aorto-mesenteric bypass using a hybrid clampless anastomosis on the supraceliac aorta was performed. The procedures were performed via laparotomy. We carried out the exposure of the anterior supraceliac aorta limited to the zone without major calcifications; then we performed a side-to-end media-adventitial anastomosis between the supraceliac aorta and a Dacron graft 7mm without any arteriotomy or clamping. The proximal graft and the aortic anastomosis site were punctured using a 18 G needle. An introducer was then positioned over a wire through the prosthetic graft and pushed into the aorta. Balloon expandable covered stenting to open and stabilize the anastomosis site was performed. Finally, the graft was tunneled to the SMA, and an end-to-side anastomosis was performed. The postoperative courses were uneventful, and the patients were promptly discharged. The follow-up, which in the first case is 4 years, showed the complete patency of the graft in each of the cases treated. The hybrid clampless anastomosis appears to be safe and useful in cases of severe aortic calcification.

Single access covered endovascular reconstruction of the aortic bifurcation

We describe the feasibility of covered endovascular reconstruction of the aortic bifurcation (CERAB) through a single femoral access and a steerable sheath. We present the technique, which we used for a patient with severe aortoiliac calcification and bilateral involvement of the common femoral artery. The patient underwent endarterectomy of the left common femoral artery plus CERAB with an aortic stent graft and bilateral covered stents for the common iliac artery with kissing dilatation with a steerable sheath using only left femoral access. CERAB can be performed using unilateral access with the aid of a steerable sheath, reducing the potential for access site complications.

Ipsilateral Aorto-Iliac Calcification is Not Directly Associated With eGFR After Kidney Transplantation: A Prospective Cohort Study Analyzed Using a Linear Mixed Model.

Aorto-iliac calcification (AIC) is a well-studied risk factor for post-transplant cardiovascular events and mortality. Its effect on graft function remains unknown. The primary aim of this prospective cohort study was to assess the association between AIC and estimated glomerular filtration rate (eGFR) in the first year post-transplant. Eligibility criteria were: ≥50years of age or ≥30years with at least one risk factor for vascular disease. A non-contrast-enhanced CT-scan was performed with quantification of AIC using the modified Agatston score. The association between AIC and eGFR was investigated with a linear mixed model adjusted for predefined variables. One-hundred-and-forty patients were included with a median of 31 (interquartile range 26-39) eGFR measurements per patient. No direct association between AIC and eGFR was found. We observed a significant interaction between follow-up time and ipsilateral AIC, indicating that patients with higher AIC scores had lower eGFR trajectory over time starting 100days after transplant (p = 0.014). To conclude, severe AIC is not directly associated with lower post-transplant eGFR. The significant interaction indicates that patients with more severe AIC have a lower eGFR trajectory after 100days in the first year post-transplant.

Abdominal Aorto-Iliac Calcification Burden Assessment Using Deep Convolutional Neural Networks for Prediction of Cardiovascular Risk Among Prostate Cancer Patients Undergoing Stereotactic Body Radiotherapy (SBRT)

<h3>Purpose/Objective(s)</h3> Cardiovascular (CV) disease is among the leading causes of death for patients with prostate cancer. One novel strategy for automated screening for CV disease is the use of opportunistic imaging biomarkers derived from CT simulation scans. This study aims to investigate association of abdominal aorto-iliac calcification burden as measured qualitatively by physicians and quantitatively using a deep learning approach, and occurrence of major adverse CV events (MACE) among prostate cancer patients undergoing SBRT. <h3>Materials/Methods</h3> A retrospective study was conducted of 146 patients undergoing SBRT for localized prostate cancer (median age 68.9 years [interquartile range, IQR, 63.6-74.0]; 23.2% low risk, 35.1% intermediate risk, 11.6% high risk) between June 2007 and August 2018. MACE was collected from review of the medical chart, defined as a composite event of stroke, myocardial infarction, hospitalization for new onset heart failure, and CV death. Two physicians who were blinded to outcomes (WCC, JDB) independently reviewed non-contrast CT simulation scans to assess aorto-iliac calcification burden by a pre-defined 5-point scale (weighted Kappa: 0.72). Next, the abdominal aorta and common iliac arteries were contoured for 50 scans which served as a training dataset. A multi-stage UNet was trained to delineate aorto-iliac contours, achieving a mean dice score of 0.87±0.08 and Hausdorff distance of 1.9±0.6mm. Calcification burden was quantified using a per-voxel threshold of >130 Houndsfield units. <h3>Results</h3> 20 patients (13.7%) experienced MACE during a cohort-wide median clinical follow up of 5.9 years (IQR 4.7-6.4), and 5 patients (3.4%) died of CV disease and 10 patients (6.8%) of other causes (1 prostate cancer related). 49 patients (33.5%) had moderate to severe CaBS of 3 or higher. CaBS was significantly positively correlated with MACE in a dose dependent manner (P<0.0001, Cochran-Armitage test for trend), increasing from 6.2% for patients with mild/absent CaBS, to 20.6%, 37.5%, and 57.1%, for CaBS of 3, 4 and 5, respectively. Quantitative calcification burden (CaQ)derived from auto-segmentation was correlated with CaBS (Pearson r=0.79, P<0.0001) and achieved a similar area under the curve (AUC 0.74 vs 0.73 for CaBS) for MACE, resulting in a sensitivity of 78%, specificity of 63%, negative predictive value of 94.8%, and positive predictive value of 24.6%, using a cut-off of 1650 mm^3. Finally, both CaBS and CaQ remained significantly associated with MACE after adjusting for age on Cox regression (P=0.04, CaQ: HR 1.15 per 1000mm^3, 95% CI 1.005-1.33). <h3>Conclusion</h3> Abdominal aorto-iliac calcification burden was strongly associated with cardiovascular risk among patients undergoing SBRT for prostate cancer. A deep learning approach to quantify calcification burden on non-contrast pelvic CT simulation scans identified patients at elevated cardiovascular risk and may facilitate automated screening.

332.10: Pre-transplant Coronary Angiography Findings Based on Coronary or Aorto-Iliac Calcification on CT Imaging in Asymptomatic Patients With a Negative Cardiac Stress Test

Purpose: Cardiac events are now the leading cause of early mortality after kidney transplantation. Long term exposure to immunosuppression also increases cardiometabolic stress after transplantation. Several studies in general population have shown that the presence of coronary artery calcification increases the risk of future cardiovascular events. Among pre-kidney transplant candidates, there remains wide variation in cardiac risk assessment practices across transplant centers. We report coronary angiography findings in asymptomatic candidates undergoing Kidney transplant evaluation with negative stress test but with findings of coronary or aorto-iliac calcification on CT imaging. Methods: We conducted a retrospective single center study of 76 Pre-Kidney transplant recipients who had a negative stress test and underwent coronary angiography between 2010 to 2021. All patients underwent coronary angiography based on coronary or aortoiliac calcification on CT imaging. Mean age was 60 years in both groups. Demographics and results are listed in table 1. Results: Results at our academic center showed that 18 out of 76 patients (23.6%) had a 70% stenosis in one or more coronary vessels. 11 out of 76 patients (14.4%) underwent single or multiple vessels stent placement and one underwent CABG. 7 out of 76 patients (9%) had significant distal disease or vessels were too small for intervention. In CAD group, 13 out of 18 patients (72%) were diabetic. All patients underwent successful kidney transplantation. Post Operative hypotension was more common in non-CAD group, in 9 patients as compared to 3 patients in CAD group. 5 patients in non-CAD recipients had post-op Atrial fibrillation Vs 1 in CAD group. Conclusions: In addition to traditional risk factors and other cardiac risk stratification modalities, Coronary or aorto-iliac calcification on CT imaging is a predictor of significant coronary artery disease in patients undergoing evaluation for kidney transplant surgery. coronary angiography before transplantation should be considered for potential candidates for Kidney transplant with negative stress test but significant vascular calcification. Table 1 - N=76 CAD=18 No CAD=58 Stent 11 NA CABG 1 NA Male/Female 12/6 34/24 Dialysis/Preemptive 12/6 46/12 DM 13 34 Former Smoker/ Nonsmoker 9/9 19/39 Months onHD (Mean) 32.2 32.4

Aorto-Iliac Artery Calcification and Graft Outcomes in Kidney Transplant Recipients.

While the association of vascular calcification with inferior patient outcomes in kidney transplant recipients is well-established, the association with graft outcomes has received less attention. With this dual-centre cohort study, we aimed to determine the clinical impact of recipient pre-transplant aorto-iliac calcification, measured on non-contrast enhanced computed tomography (CT)-imaging within three years prior to transplantation (2005–2018). We included 547 patients (61.4% male, age 60 (interquartile range 51–68) years), with a median follow-up of 3.1 (1.4–5.2) years after transplantation. The aorto-iliac calcification score (CaScore) was inversely associated with one-year estimated-glomerular filtration rate (eGFR) in univariate linear regression analysis (standard β −3.3 (95% CI −5.1 to −1.5, p < 0.0001), but not after adjustment for potential confounders, including donor and recipient age (p = 0.077). In multivariable Cox regression analyses, a high CaScore was associated with overall graft failure (p = 0.004) and death with a functioning graft (p = 0.002), but not with death-censored graft failure and graft function decline. This study demonstrated that pre-transplant aorto-iliac calcification is associated with one-year eGFR in univariate, but not in multivariable linear regression analyses. Moreover, this study underlines that transplantation in patients with a high CaScore does not result in earlier transplant function decline or worse death censored graft survival, although ongoing efforts for the prevention of death with a functioning graft remain essential.

Aorto-Iliac Artery Calcification Prior to Kidney Transplantation.

As vascular calcification is common in kidney transplant candidates, aorto-iliac vessel imaging is performed for surgical planning. The aim of the present study was to investigate whether a novel non-contrast enhanced computed tomography-based quantification technique for aorto-iliac calcification can be used for cardiovascular risk stratification prior to kidney transplantation. In this dual-center cohort study, we measured the aorto-iliac calcium score (CaScore) of 547 patients within three years prior to transplantation (2005–2018). During a median (interquartile range) follow-up of 3.1 (1.4, 5.2) years after transplantation, 80 (14.7%) patients died, of which 32 (40.0%) died due to cardiovascular causes, and 84 (15.5%) patients had a cardiovascular event. Kaplan-Meier survival curves showed significant differences between the CaScore tertiles for cumulative overall-survival (Log-rank test p < 0.0001), cardiovascular survival (p < 0.0001), and cardiovascular event-free survival (p < 0.001). In multivariable Cox regression, the aorto-iliac CaScore was associated with all-cause mortality (hazard ratio 1.53, 95%CI 1.14–2.06, p = 0.005), cardiovascular mortality (2.04, 1.20–3.45, p = 0.008), and cardiovascular events (1.35, 1.01–1.80, p = 0.042). These independent associations of the aorto-iliac CaScore with the outcome measures can improve the identification of patients at risk for (cardiovascular) death and those who could potentially benefit from stringent cardiovascular monitoring to improve their prognosis after transplantation.

A new aortoiliac calcification scoring system to predict grade C anastomotic leak following rectal cancer surgery.

Aortoiliac calcification may be a surrogate marker of decreased visceral perfusion causing anastomotic leak (AL). The aim of this study was to evaluate the predictive role of aortoiliac calcification for AL after rectal cancer surgery. We enrolled patients with primary rectal cancer who had restorative resection at our institution between January 2013 and December 2015. An aortoiliac calcification score was calculated as the sum of calcification scores at the infrarenal aorta (0: no, 1: ≤ 3cm, 2: > 3cm) and the common iliac arteries (0: no, 1: unilateral, 2: bilateral).AL was classified into three grades: grade A, requiring no intervention; grade B, requiring therapeutic intervention without re-laparotomy; and grade C, requiring re-laparotomy. Clinicopathological characteristics were analyzed to identify risk factors for AL. There were 583 patients. Three-hundred forty-five (59.2%) had an aortoiliac calcification score ≥ 3, and 37 (6.3%) patients experienced AL, in 30 cases (5.1%) grade C AL. Patients with an aortoiliac calcification score ≥ 3 had a higher incidence of grade C AL (6.7% vs. 2.9%, p = 0.045). Multivariate logistic regression analysis revealed that an aortoiliac calcification score ≥ 3 was an independent risk factor for grade C AL (odds ratio = 2.669, 95% confidence interval 1.066-6.686, p = 0.036). Aortoiliac calcification may be considered a risk factor for grade C AL after rectal cancer surgery.

Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR

Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events. All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range. About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P=0.33). Nine patients (2.2%) died within 30days of the operation, whereas the remaining were followed up for 6.3 (4.7-8.4) years. The iliofemoral calcium score was 8348 (3830-14,179). Estimated overall survival at 5years was 73±2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5years: 79±4% vs. 71±3%; P=0.01) and cardiac event-free survival (5years: 95±2% vs. 91±2%; P=0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988-1.045]; P=0.268) nor cardiac event-free survival (odds ratio, 1.024 [0.986-1.063]; P=0.222). Low iliofemoral calcium score may be associated with lower incidence of fatalcardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further.

Lower extremity arterial calcifications assessed by multislice CT as a correlate to coronary artery disease

BackgroundPatients with peripheral artery disease (PAD) frequently have concomitant coronary artery disease (CAD) and display a higher risk for myocardial infarction, stroke, and death due to cardiovascular events. In order to prevent cardiovascular events, there is an increasing interest in new markers of atherosclerosis. Vascular calcifications (VC) are often present in the early stages of atherogenesis and could be considered an early marker. The aim of this study is to correlate the extent of lower limbs, aortic, and coronary arterial calcification diagnosed by non-contrast multislice CT with the severity of coronary artery disease diagnosed by conventional coronary angiography.ResultsThere is borderline significant association between CAD (Gensini score) and each of total lower limb and aorto-iliac calcifications. There is significant association between the number of diseased coronaries and lower limb calcifications. Also, there is significant association between the coronary artery calcifications and lower limb arterial calcifications (total and segmental).Diabetes mellitus and hypertension are significantly associated with lower limb calcification (total, aorto-iliac, and infra-popliteal). Moreover, lower limb arterial calcifications (total and segmental) are positively correlated with increasing age.ConclusionLower limb arterial calcifications, as diagnosed by non-contrast MSCT, is a noninvasive measure for evaluation of the atherosclerotic burden that correlate to the CAD; it can aid to refine risk stratification and the need for more aggressive preventive strategies.

Multicentric Long-Term Results of Aorto Bi Femoral Bypasses Performed Before Kidney Transplantation

Introduction - Kidney recipients are increasingly older, leading to extended aorto iliac calcifications that can contra-indicate transplantation in absence of previous procedure to get a safe and suitable access even in asymptomatic patients. We aimed to describe the results of aorto bi femoral bypasses performed as a preparation for kidney transplantation. Methods - This retrospective multicentric study included 89 patients (76 men) over 11university centers, mean age of 55.9 (27-76), who underwent revascularization from 1984 to 2016 by transperitoneal (n=75), retroperitoneal (n=11) and 3 times coelioscopic approaches. Vascular prosthesis was PET (n=84) or PTFE (n=5). Nineteen have had previous kidney transplantation, 79 were on dialysis at time of surgery. A subgroup analysis was performed depending on Rutherford class: 36 class 0 and 1 were included in group I (GI) and 53 class 2 to 6 in group II (GII). Results - Overall major complications after bypass surgery were 14/89 (15.7%): 2 infections, 6 ischemia (2 mesenteric, 1 medullar, 3 limb occlusions), 4 hemorrhages and 2 myocardial infarctions. The latest were responsible of a 30-day mortality of 2/89 (2.2%), 2.8% in GI (1/36) and 1.9% in GII (1/53). There was no lost of follow-up with a mean duration of 6.3 years. According to Kaplan-Meier analysis, at 1 and 5 years, survival was respectively 92.7% and 75.7% for overall population, 97% and 92.9% for GI, 93.5% and 69.6% for GII. Survival was significantly higher in GI (log-rank p=0.044). Five-year primary patency was 88.4% without significant difference between GI and GII (96.3% vs 81.8%). In GI, 13 patients had secondary procedures (5 limb occlusions, 2 infections, 6 run-off impairment) vs 16 in GII (8 limb occlusions, 5 infections, 3 run-off impairment). In the overall population, 47 patients underwent kidney transplantation (52.8%), 20 in GI (55.6) and 27 in GII (51%). Overall mean time from waiting list inscription to kidney transplantation was 26±29 months, significantly shorter in GI (1.2±0.9 vs 2.8±2.9, p=0.038). Eleven patients among 89 (12.4%) died before transplantation, 3 in GI (8.3%) vs 8 (15.1%). Fourteen remain on waiting list, 2 (5.6%) in GI vs 12 (21.4%). Seventeen patients (19.1%) are currently under temporary contra-indication, 10 (27.8%) in GI vs 7 (13.2%). At time of transplantation, arterial anastomosis was performed on the vascular prosthesis in 46 of the 47 cases. Mean warm ischaemia duration was 66±34 min. Overall 30-Day mortality after transplantation was 2.1% (1/47) solely in GI. At discharge, mean creatinine clearance was 35.9±19.4 ml/min/1.73 m2. Graft loss occurred in 17% (8/47) and at last follow up mean creatinine clearance was 43.6±17.7 ml/min/1.73 m2. Conclusion - In end stage renal disease patients, aorto bi femoral bypass is an effective strategy to prepare kidney transplantation. It provides acceptable long-term results despite a high rate of secondary arterial reinterventions. This strategy poses a life-threatening risk in initially asymptomatic patients without any guarantee to undergo transplantation. This could be considered as an ethical key-point.

The relationship between aortoiliac calcification and long-term outcome in rectal cancer resection.

705 Background: The interaction between host and tumour factors is an important determinant of long-term outcome following rectal cancer resection. At cellular level, hypoxia within the tumour microenvironment stimulates neovascularisation, alters tumour metabolism and is implicated in dissemination and metastases. At host level, restricted blood flow to the tumour may play a role in tumour hypoxia. Significant calcification of the distal aortic and iliac arteries could result in impaired rectal perfusion. We aimed to investigate the relationship between aortoiliac calcification (AC) and long-term outcome following rectal cancer resection. Methods: Patients were identified from a prospectively maintained database. Recurrence and survival data were abstracted. On staging CT images, the sum of calcified quadrants of the distal aorta and iliac arteries at the level of the bifurcation was calculated. ROC analysis was used to identify the optimum threshold for determining significant calcification. Results: Between 2008-2016, 181 patients with available CT scans underwent surgery for rectal cancer. Most were male (60%), aged over 65 (53%) and TNM stage II/III (72%). Median follow-up was 63 months. Significant AC was identified in 44 patients (24%). Recurrence occurred in 42 patients: local in 16 (9%) and systemic in 26 (14%) patients. Recurrence was associated with significant AC (p = 0.017), TNM stage (p = 0.002) and venous invasion (p = 0.006). When considering those with and without significant AC, there were differences in the rates of local (11% vs. 8%) and systemic (25% vs. 11%) recurrence respectively (p = 0.043). On univariate Cox regression analysis, overall survival was related to age (p = 0.012), ASA grade (p = 0.042) and significant AC (p = 0.001). On multivariate analysis, significant AC (p = 0.011) was the only independent predictor of overall survival. Conclusions: The burden of aortoiliac calcification appears to play an important role in influencing long-term outcome following rectal cancer resection, independent of traditional determinants such as TNM stage and ASA grade. While validation is required, further investigation of the mechanism underlying this relationship is warranted.

Aortoiliac calcification correlates with 5-year survival after abdominal aortic aneurysm repair

BackgroundAn anatomic severity grade (ASG) score to categorize and to define anatomic factors for abdominal aortic aneurysm (AAA) repair was proposed. Other studies have previously reported that aortic anatomic complexity is a marker of survival and resource utilization after repair, although it remains unclear whether individual components of the ASG score independently contribute to survival. This study analyzed and validated an aortic and iliac artery calcium scoring system that can potentially predict survival after AAA repair. MethodsPatients who underwent infrarenal AAA repairs from July 2007 to May 2012 were analyzed using complete 5-year records. Those who died ≤30 days of surgery were excluded. Calcium score (CS) was defined using the ASG scoring system for its basis by preoperative imaging <6 months before surgery. A CS for any patient was 0 to 5 points, the sum of the points assigned to aortic neck (2 points total) and iliac artery (3 points total) calcification. A receiver operating characteristic curve was used to determine a CS threshold for mortality. The 5-year survivors and deaths were compared in regard to comorbidities, pharmacology, and CS at or above the defined threshold. Each variable with a P value <.1 between the groups was then placed into a Cox proportional hazards model, with statistical significance of P < .05. ResultsThere were 356 patients who underwent AAA repair with complete 5-year follow-up data; 26% died within 5 years of surgery. Of these, 13% had CS of 0 with 15% mortality, 28% had CS of 1 with 21% mortality, 24% had CS of 2 with 24% mortality, 23% had CS of 3 with 35% mortality, 10% had CS of 4 with 40% mortality, and 2% had CS of 5 with 17% mortality. The receiver operating characteristic curve demonstrated an appropriate threshold of CS 3. Of these patients, 65% had a CS <3, whereas 35% had a CS ≥3. Patients with a CS ≥3 had a lower 5-year survival probability (P = .003). Comparing 5-year survivors and deaths in a Cox proportional hazards analysis, CS ≥3 was associated with a hazard ratio of 1.579 (95% confidence interval, 1.038-2.402; P = .0328). ConclusionsA CS ≥3 is linked to a lower 5-year survival after AAA repair in our population. This system potentially can be another measure for risk stratification and serve as a means to predict midterm mortality in AAA repairs. Future study will be needed for further validation to predict midterm mortality and to better guide surgical decision-making.

The Impact of Aorto-iliac Calcifications on Patient and Graft Survival in Renal Transplant Recipients Using the TASCII Classification

Introduction Kidney transplantation is the therapy of choice in patients with end-stage renal disease. Aorto-iliac calcifications are a relative contra-indication for renal transplantation, even though the influence on patient and graft survival remains poorly explored. Aorto-iliac calcifications can be classified using the Trans Atlantic Inter-Society Consensus (TASC) II classification, which is based on the presence and extent of aorto-iliac stenotic lesions. The aim of this study is to assess the impact of aorto-iliac calcifications on patient and graft survival using the TASC II classification. Methods This retrospective single-center study included all kidney transplant recipients from 2000-2016 who had imaging-proven pre-transplantation aorto-iliac stenotic lesions. Patients were classified according to the TASC II classification if aorto-iliac stenotic lesions were present. All patients transplanted between 2007-2011 without aorto-iliac stenotic lesions were used as a control group. Primary endpoints were patient and graft survival. Cox regression analysis was used to evaluate risk factors for mortality and graft loss. Results Aorto-iliac stenotic lesions were observed in 78 patients before kidney transplantation. Seven hundred seventy-three patients were included as a control group. Overall patient survival was decreased for every TASC II class (TASC II A: p=0.001; B: p=0.004, C: p<0.001, D: p<0.001). No significant difference was found for 90-day mortality (TASC II A p=0.165; B p=1.000; C p=1.000) and 1-year mortality (TASC II A p=0.143; B p=1.000; C p=1.000) in patients with TASC II A, B or C lesions. Patients with TASC II D lesions had significantly higher 90-day (p=0.006) and 1-year (p <0.001) mortality. Death-censored graft survival was not significantly decreased for TASC II A, B and C compared to the control group (TASC II A p=0.792; B p=0.950; C p=0.160). Multivariate Cox model showed that any TASC II lesion was not a predictor of overall mortality (hazard ratio (HR) 1.52 confidence interval (CI) 0.94-2.46 p=0.091) or graft loss (HR 1.72; CI 0.94-3.17; p=0.080). Discussion This study demonstrates favorable outcomes in patients with TASC II A, B or C lesions with no increased mortality in the postoperative period. As expected, overall patient survival is decreased in patients with TASC II lesions because of cardiovascular comorbidity. The most striking result is similar death-censored graft survival in patients with TASC II A, B or C lesions and patients without any aorto-iliac stenotic lesions. Therefore, kidney transplantation in those patients is possible with favorable outcomes. The TASC II classification seems to be useful to predict patient outcomes. Conclusion Kidney transplantation is a safe procedure in patients with TASC II A, B and C lesions. Graft survival is unaffected by aorto-iliac stenotic lesions. Therefore, aorto-iliac calcifications should not be a contra-indication for kidney transplantation.

Aortic bypass surgery for asymptomatic patients awaiting a kidney transplant: A word of caution.

In the presence of severe aorto-iliac calcification, aortic bypass surgery can be mandatory to allow kidney transplantation. The aim of our study was to evaluate the safety and outcomes of this strategy among asymptomatic patients. We retrospectively reviewed the files of all patients that had undergone vascular bypass surgery prior to kidney transplantation between November 2004 and March 2016. All patients undergoing aortic bypass surgery prior to kidney transplantation without any vascular-related symptoms were included. Twenty-one asymptomatic patients were included. Ten patients (48%) have not received a kidney transplant. Four patients died before kidney transplantation, including 2 deaths related to the bypass surgery (9.5%). Early post-operative morbidity involved 11 cases. Eleven patients (52%) were transplanted. Transplanted patients were significantly younger (median age 60 [56-61] vs 67 [60-72] years, P=.04) at the time of bypass and were less frequently treated for coronary heart disease (9% vs 50%, P=.06). Aortic bypass surgery performed prior to kidney transplantation among asymptomatic patients has significant mortality and morbidity rates. When transplantation is possible, the results are satisfying. Larger studies are required to define the selection criteria, such as age and coronary heart disease.

Vascular calcification, response to neoadjuvant radiotherapy and survival of patients with rectal cancer

Background: Abdominal aortic calcification impairs visceral blood flow, and has been associated with post-operative morbidity in patients undergoing abdominal surgery. However, the effect of vascular calcification on tumour response to neoadjuvant therapy, or survival, has not previously been examined. The present study examined the relationship between aortoiliac calcification, tumour response and cancer-specific and overall survival (CSS/OS) of patients with rectal cancer.