Medial arterial calcification in ageing and disease: current evidence and knowledge gaps

Medial arterial calcification (MAC) characterizes human arterial ageing, potentially remaining clinically silent for decades. However, in susceptible individuals and patients with diabetes mellitus and chronic kidney disease, it becomes a critical risk factor for cardiovascular morbidity and mortality, and it is a significant risk factor for chronic limb-threatening ischaemia and limb amputation. A key biological feature of MAC pathogenesis is the phenotype switching of vascular smooth muscle cells, ultimately responsible for the deposition of hydroxyapatite crystals and the progressive medial layer destruction associated with intimal thickening. The signalling pathways targeting the vascular smooth muscle cells in ageing and disease are partly shared. Due to the MAC-related arterial wall stiffening and intimal thickening, MAC fundamentally alters central and peripheral haemodynamics. Yet, a comprehensive understanding of MAC's impact on haemodynamics is lacking. Ankle-brachial index, ultrasound, and X-ray radiography can detect only advanced MAC in the clinical setting. Due to the slow progression, MAC provides many early detection, prevention, and timely intervention targets. However, no effective pharmacological treatment is currently available to alter its course, and revascularizations remain the only treatment option in symptomatic patients. To prevent, reverse, or delay MAC, further research is needed to reveal the complete picture of molecular pathogenesis and haemodynamic impact of MAC vasculopathy.