title: Impact of Calcification on Clinical Outcomes After Endovascular Therapy for Superficial Femoral Artery Disease: Assessment Using the Peripheral Artery Calcification Scoring System.
abstract: To investigate whether the severity of lesion calcification assessed by the novel peripheral artery calcification scoring system (PACSS) was associated with clinical outcomes after endovascular therapy (EVT) for superficial femoral artery (SFA) lesions.
  
  
  
  A retrospective analysis was conducted of 394 consecutive patients (mean age 72±8 years; 290 men) with intermittent claudication [223 (57%) with diabetes, 81 (21%) on hemodialysis] who underwent successful EVT for de novo SFA lesions [length 152.1±95.7 mm; 199 (50%) TransAtlantic Inter-Society Consensus II class C/D] between January 2010 and December 2013. The patients were retrospectively categorized using the PACSS classification (grades 0-4: no visible calcification of the target lesion, unilateral wall calcification <5 cm, unilateral calcification ≥5 cm, bilateral wall calcification <5 cm, and bilateral calcification ≥5 cm, respectively). The main outcome was primary patency, while the secondary outcome measures were mortality and major adverse limb events [MALE: any intervention (repeat EVT or surgical revision) or major (above ankle) amputation]. Cox proportional hazards analysis was used to explore whether the PACSS classification was an independent predictor of clinical outcomes. Results are presented as the hazard ratio (HR) and 95% confidence interval (CI).
  
  
  
  The distribution of PACSS grades was 0 in 54%, grade 1 in 16%, grade 2 in 12%, grade 3 in 9%, and grade 4 in 9%. The 2-year primary patency rates in these grades, respectively, were 70.0%, 66.6%, 72.1%, 55.6%, and 36.3% (p<0.001). After multivariate analysis, PACSS grade 4 (HR 2.74, 95% CI 1.56 to 4.83, p<0.001), diabetes (HR 1.52, 95% CI 1.06 to 2.20, p=0.022), lesion length (HR 1.04, 95% CI 1.01 to 1.07, p=0.006), and vessel diameter (HR 0.80, 85% CI 0.65 to 0.98, p=0.038) were associated with loss of primary patency. PACSS grade 4 was also associated with MALE and mortality (p=0.048 and 0.011, respectively). Bare metal stent use (HR 0.47, 95% CI 0.30 to 0.73, p<0.001) was positively associated with primary patency.
  
  
  
  PACSS grade 4 calcification was independently associated with clinical outcomes after EVT for de novo SFA lesions.
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Shota
authors.initials: S
authors.lastname: Okuno
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan iida.osa@gmail.com.
authors.forename: Osamu
authors.initials: O
authors.lastname: Iida
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Shiraki
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Masashi
authors.initials: M
authors.lastname: Fujita
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Masaharu
authors.initials: M
authors.lastname: Masuda
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Shin
authors.initials: S
authors.lastname: Okamoto
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Takayuki
authors.initials: T
authors.lastname: Ishihara
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Kiyonori
authors.initials: K
authors.lastname: Nanto
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Kanda
authors.affiliation: Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Mitsuyoshi
authors.initials: M
authors.lastname: Takahara
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan.
authors.forename: Masaaki
authors.initials: M
authors.lastname: Uematsu
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000792:Angiography; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D055109:Ankle Brachial Index; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D061205:Vascular Calcification / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D014654:Vascular Patency
keywords: angioplasty; calcification; calcium scoring system; endovascular therapy; peripheral artery disease; stent; superficial femoral artery