Precision Imaging Evaluation and Clinical Application Progress of Vascular Calcification in Lower Extremity Peripheral Artery Disease.

BACKGROUND

Lower extremity peripheral artery disease (PAD) affects a large and growing global population. Vascular calcification is a common and clinically important feature that impairs diagnostic accuracy, increases procedural complexity, and adversely affects long-term outcomes. This review summarizes the pathophysiological basis, precision imaging evaluation, and clinical application of lower extremity arterial calcification in PAD.

METHODS

We conducted a comprehensive literature search and synthesized evidence on the pathophysiological mechanisms, multimodal imaging techniques (including X-ray, ultrasound, computed tomography (CT), magnetic resonance imaging, digital subtraction angiography, optical coherence tomography (OCT), and nuclear medicine), and imaging-guided treatment strategies for calcified lower extremity PAD.

RESULTS

Arterial calcification in PAD is classified into intimal and medial types, with distinct mechanisms and clinical consequences. Multimodal imaging provides complementary information: CT remains central for macrocalcification assessment; ultrasound offers accessible hemodynamic and morphological data; intravascular imaging (intravascular ultrasound and OCT) enables high-resolution intraprocedural evaluation; and 18F-NaF positron emission tomography/CT provides emerging insight into active microcalcification. Treatment selection should be guided by imaging-defined calcium characteristics, with intravascular lithotripsy for deep/concentric calcium, atherectomy for eccentric/luminal lesions, and drug-coated balloons or stenting for appropriately selected cases.

CONCLUSION

Precision imaging has progressed from simple detection to comprehensive evaluation of calcium burden, morphology, distribution, type, and activity. By linking imaging-defined calcium characteristics with vessel preparation, revascularization strategy, and prognosis, multimodal imaging has the potential to improve individualized treatment planning for calcified PAD. However, standardized scoring systems, prospective outcome-based validation, and integration of functional imaging and artificial intelligence-assisted analysis are still required for routine clinical translation.