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. 2008 May 20;51(20):1967-74.
doi: 10.1016/j.jacc.2007.12.058.

Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease

Raul J Guzman  1 , D Marshal Brinkley, Paul M Schumacher, Rafe M J Donahue, Holly Beavers, Xiao Qin
Affiliations

Tibial artery calcification as a marker of amputation risk in patients with peripheral arterial disease

Raul J Guzman et al. J Am Coll Cardiol. .

Abstract

Objectives: The purpose of this study was to evaluate the relationship between calcification in tibial arteries, the degree of limb ischemia, and the near-term risk of amputation.

Background: Determining the amputation risk in patients with peripheral arterial disease (PAD) remains difficult. Developing new measures to identify patients who are at high risk for amputation would allow for targeted interventions and focused trials aimed at limb preservation.

Methods: Two hundred twenty-nine patients underwent evaluation by history, arterial Doppler, and multislice computed tomography of the lower extremities. We then explored the relationship between a tibial artery calcification (TAC), traditional risk factors for PAD, limb status at presentation, and near-term amputation risk.

Results: Increased age and traditional atherosclerosis risk factors were associated with higher TAC scores. Patients with critical limb ischemia had the highest TAC scores, and increasing TAC scores were associated with worsening levels of limb ischemia in ordinal regression analysis. Receiver-operator characteristic analysis suggested that the TAC score predicted amputation better than the ankle-brachial index (ABI). Symptomatic patients with a TAC score greater than 400 had a significantly increased risk of amputation. In Cox regression analysis, there was a strong association between the TAC score and the risk of major amputation that remained after adjustment for traditional risk factors and the ABI.

Conclusions: In patients presenting with PAD, the TAC score is associated with the stage of disease and it identifies those who are at high risk for amputation better than traditional risk factors and an abnormal ABI.

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Conflict of interest statement

Conflicts of interest: None

Figures

Figure 1
Figure 1. Tibial artery calcification
Non-contrasted MSCT showing patient without (A) and with (B) significant tibial artery calcification. Arrows identify calcified tibial arteries.
Figure 2
Figure 2. TAC scores by limb status
TAC scores in patients without (control) and with PAD (claudication and CLI). Each dot represents a single patient. Open circles represent patients who subsequently underwent major amputation. Bars represents median for each group.
Figure 3
Figure 3
Clinical presentation by TAC range. Patients were divided according to TAC categories (0–10, 10–1000, and >1000). Bars represent number of patients with no disease (controls), claudication (gray bars), or CLI (black bars).
Figure 4
Figure 4. Receiver operator characteristic analysis
ROC curves for the predictive value of TAC and ABI on major amputation (A) and on major and minor amputation (B). The bold line represents the ROC curve for TAC score. The continuous line represents ROC curve for ABI. The dotted line represents no effect. AUC = area under the curve. TAC = tibial artery calcium score. ABI = ankle brachial index.
Figure 5
Figure 5. Major amputation events according to TAC score for patients with PAD
Symptomatic vascular patients were stratified by TAC scores greater than or less than 400. Kaplan-Meier curves were derived for major amputation-free survival. The p value is derived using the log-rank test. Number of patients at risk at each time point is listed on bottom.
See this image and copyright information in PMC

Comment in

  • Footnotes on critical limb ischemia.
    Feiring AJ. Feiring AJ. J Am Coll Cardiol. 2008 May 20;51(20):1975-6. doi: 10.1016/j.jacc.2008.02.041. J Am Coll Cardiol. 2008. PMID: 18482667 No abstract available.

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