Carotid calcium burden derived from computed tomography angiography as a predictor of all-cause mortality after carotid endarterectomy

Franziska Röder, Louise B.D. Banning, Reinoud P.H. Bokkers, Jean Paul P.M. de Vries, Richte C.L. Schuurmann, Clark J. Zeebregts, Robert A. Pol*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Objective: Carotid endarterectomy (CEA) aims to reduce the risk of stroke in patients with atherosclerotic carotid disease. Preoperative risk assessments that predict complications are needed to optimize the care in this patient group. The current approach, namely relying solely on symptomatology and degree of stenosis, is outdated and calls for innovation. The Agatston calcium score was applied in several vascular specialties to assess cardiovascular risk profile but has been little studied in carotid surgery. It is hypothesized that a higher calcium burden at initial presentation equates to a worse prognosis attributable to an increased cerebrovascular and cardiovascular risk profile. The aim was to investigate the association between preoperative ipsilateral calcium score and postoperative all-cause mortality in patients undergoing CEA. Methods: This single-center retrospective cohort study included 89 patients who underwent CEA at a tertiary referral center between 2010 and 2018. Preoperative calcium scores were measured on contrast-enhanced computed tomography images with patient-specific Hounsfield thresholds at the level of the carotid bifurcation. The association between these calcium scores and all-cause mortality was analyzed using multivariable adjusted Cox proportional hazard analysis. Results: Cox proportional hazard analysis demonstrated a significant association between preoperative ipsilateral carotid calcium score and all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.16; P = .003). After adjusting for age, preoperative estimated glomerular filtration rate, and diabetes mellitus, a significant association remained (hazard ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .05). Conclusions: A higher calcium burden was predictive of worse outcome, which might be explained by an overall poorer health status. These results highlight the potential of calcium measurements in combination with other traditional risk factors, for preoperative risk assessment and thus for improved patient education and care.

Original languageEnglish
Pages (from-to)995-1002
Number of pages8
JournalJournal of vascular surgery
Issue number4
Early online date29 May 2023
Publication statusPublished - Oct 2023
Externally publishedYes


  • Carotid
  • Carotid stenosis
  • Endarterectomy
  • Mortality
  • Premature
  • Vascular calcification


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