Dense Calcification of the Common Femoral Artery Is Protective Against In-Stent Restenosis.

Background

Vascular calcification has been highlighted as a prognostic factor for perioperative thrombosis but a protective factor for late restenosis in lower limb peripheral artery disease (LLPAD). The aim of this study was to investigate the association between calcification and twelve-month primary patency in patients with stenting of the common femoral artery (CFA) and its bifurcation for atheromatous stenosis. Materials/

Methods

This single-center retrospective study analyzed consecutive limbs (n = 90) that underwent CFA stenting for symptomatic lesions between January 2018 and January 2023. Calcification was assessed using dedicated computed tomography angiography analysis software (EndoSize; Therenva), with blinded evaluation of volume (mm3) and density (Hounsfield Units) across three anatomically distinct zones: proximal CFA (Zone 1); distal CFA (Zone 2); and bifurcation segments (Zone 3). The primary endpoint was twelve-month primary patency, defined as a peak systolic velocity ratio (PSVR) < 2.4 on duplex ultrasound without target lesion revascularization. Secondary endpoints included predictors of restenosis using multivariable logistic regression.

Results

Ninety cases of CFA stenting for LLPAD (lower limb peripheral artery disease) were analyzed. A total of 78.9% of CFA lesions were treated for claudication and 21.1% for critical limb-threatening ischemia (CLTI). Lesions were distributed as Azema types I (1%), II (43%), and III (56%). At twelve-month follow-up, primary patency (PSVR < 2.4) was achieved in 77.4% of limbs. Patent CFA stenting demonstrated significantly higher median calcification density in Zone 2 compared to those with restenosis (1122 [IQR: 903-1248] vs. 858 [788-987] HU; p = 0.006; q = 0.021 after false discovery rate correction). ROC curve analysis identified a density threshold of 800 HU with a 76% reduction in restenosis risk (OR 0.24; 95% CI: 0.08-0.72; p = 0.011). Bootstrap validation (1000 replications) confirmed threshold stability at 821 HU (95% CI: 656-990 HU).

Conclusions

In this exploratory study, dense calcification (≥800 HU) in the distal CFA appears to be protective against twelve-month restenosis following stenting. These findings suggest that calcification density may serve as a valuable predictor for patient selection and procedural planning in CFA interventions.