Association of mammographically detected breast arterial calcification with carotid doppler structural and hemodynamic parameters

Authors

Abstract

AimTo evaluate the association between mammographically detected breast arterial calcification (BAC) and carotid Doppler parameters, as well as clinical risk factors.
MethodsThis retrospective study included 104 women who underwent both mammography and carotid Doppler ultrasonography. BAC presence and grade were assessed on mammography. Clinical characteristics and carotid Doppler parameters, including common carotid artery intima–media thickness (CCA-IMT) and internal carotid artery (ICA) Doppler parameters, were compared according to BAC status and grade. Logistic regression analyses were performed to identify independent predictors of BAC.
ResultsA total of 104 patients were included (52 with BAC and 52 without BAC). BAC was associated with older age (p<0.001), diabetes mellitus (p<0.001), and hypertension (p=0.026). Carotid Doppler evaluation demonstrated that ICA peak systolic velocity (PSV) and end-diastolic velocity (EDV) were significantly lower in BAC (+) patients (p<0.001 for both), while ICA resistive index (RI) was significantly higher (p=0.034). No significant association was observed between CCA- IMT or plaque. In multivariate analysis, diabetes mellitus (OR 8.08), hypertension (OR 2.86), older age (OR 1.04), lower ICA PSV (OR 0.97), lower ICA EDV (OR 0.95), and higher ICA RI (OR 1.58) were identified as independent predictors of BAC.
ConclusionBAC is associated with altered carotid hemodynamics and cardiovascular risk factors, suggesting a relationship with systemic arterial stiffness rather than intimal atherosclerosis.

Keywords

Introduction

Mammography is a widely used, cost-effective, and accessible screening tool for breast cancer in women over 40 years of age. Breast arterial calcification (BAC) is an incidental finding, typically considered benign according to BI-RADS classification.¹ The prevalence of BAC in routine mammograms among women over 50 years is estimated to range from 8.2% to 12% ² and is more frequently observed in older and postmenopausal women.^3,4 On mammography, BAC appears as linear, parallel lines, giving a 'tram-track' or ring-like appearance when seen in cross-section, clearly associated with blood vessels.⁵ The underlying pathology of arterial calcification detected on mammography is Mönkeberg medial calcific sclerosis.⁶ Unlike intimal calcification, medial calcification usually does not lead to significant lumen narrowing; instead, it causes arterial stiffness.^7,8
Previous studies have emphasized the potential clinical relevance of BAC beyond breast imaging by linking it to a variety of cardiovascular risk factors. Reported associations include coronary artery disease (CAD), hypertension, diabetes, dyslipidemia, carotid plaques, visceral obesity, chronic kidney disease (CKD), and ischemic stroke.[6,8–11] Therefore mammography, may provide an opportunity for cardiovascular risk assessment in asymptomatic women.
Color Doppler ultrasonography (CDUS) offers a noninvasive method for assessing both the anatomical structure and hemodynamic properties of the carotid arteries. Several studies investigated the relationship between the presence of BAC on mammography and carotid intima-media thickness (IMT).^3,6,8,9,10 To our knowledge, only Büyükkaya et al. have previously investigated both the structural and hemodynamic changes of the carotid arteries in relation to BAC.⁸ However, unlike their study, which focused primarily on the common carotid artery (CCA), our study evaluated both structural and hemodynamic alterations in the CCA and the internal carotid artery (ICA).
Although various studies have investigated the relationship between BAC and carotid IMT, less attention has been paid to the potential link between BAC and carotid hemodynamic parameters. Previous research has mostly focused on structural indicators of atherosclerosis, whereas functional vascular alterations that cause arterial stiffness have received less attention. Evaluating ICA Doppler results may reveal further information about the vascular effects of BAC. Therefore, we aimed to evaluate the association between BAC and carotid Doppler parameters, particularly ICA hemodynamics, and to identify independent predictors of BAC.

Materials and Methods

Patient SelectionThis was a retrospective, single-center study. This study was approved by the Ethical Committee of Amasya University Faculty of Medicine (13 April 2023, number: 2023/36) and was conducted according to the Declaration of Helsinki and Good Clinical Practice. Because the study was retrospective, the requirement for written informed consent was waived by the Ethics Committee.
Study inclusion criteriaWe reviewed female patients aged 40 and older who underwent routine mammography between October 2024 and December 2025 at our institution's mammography workstation. Among these, those who additionally underwent carotid CDUS were consecutively included in the study.
Patients whose mammograms exhibited image artifacts caused by patient- or device-related factors that interfered with evaluation, who were unable to cooperate during carotid CDUS, or who had a known history of vascular surgery or carotid artery stenosis or occlusion were excluded from the study.
Radiological evaluation*Mammography**
Mammographic imaging of both breasts was performed using our mammography device (IMS Giotto TOMO, Italy), capturing both the mediolateral oblique (MLO) and craniocaudal (CC) views. Bilateral digital mammograms of 104 patients were independently reviewed by two radiologists with 19 and 10 years of experience in general radiology at the mammography workstation. The radiologists were blinded to the patients’ carotid Doppler ultrasound results. Patients showing typical linear, parallel calcifications resembling a tram-track appearance in at least one breast were classified as BAC (+), whereas those without such findings were classified as BAC (–). BAC severity was further graded according to the scoring system described by Mstafavi et al.: grade 0, no calcification; grade I, minor punctate calcifications; grade II, coarse, tram-track, or ring-type calcifications in <3 vessels; grade III, coarse calcifications in ≥3 vessels (Figure 1).¹¹
Carotid Artery Doppler UltrasonographyBilateral carotid CDUS examinations were performed in all 104 patients by two radiologists with 19 and 11 years of experience using an ultrasound machine (Samsung RS85 Prestige; Samsung Medison Co, Seoul, Korea) with a 2.0–14.0 MHz linear transducer. The radiologists were blinded to patients’ age and mammography findings. Examinations were performed with patients in the supine position, with the neck turned approximately 45° to the opposite side. CCA intima–media thickness (IMT) was measured in B-mode from plaque-free segments at least 1 cm proximal to the carotid bifurcation, and the average of three measurements from the posterior wall was recorded. The measurement included both the intima (the echogenic layer) and the media (the echo-weak layer).¹² Spectral Doppler parameters of both ICAs, including peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index (RI), were measured with the Doppler sample volume aligned parallel to the vessel lumen at an angle of 45–60° (Figure 2).
Statistical analysisStatistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Normality was assessed with the Kolmogorov–Smirnov test. Non-normally distributed variables were expressed as median and interquartile range (IQR). Continuous variables were compared using the Mann-Whitney U test, and categorical variables using the Chi-square test or Fisher's exact test.
Comparisons between BAC degree groups were performed using the Kruskal-Wallis test followed by Mann-Whitney U post-hoc analyses. Logistic regression analysis was used to identify independent factors associated with BAC; variables with p<0.10 in univariate analysis were included in multivariate models. Model fit was assessed using the Hosmer-Lemeshow test, and p<0.05 was considered statistically significant.

Results

Baseline characteristics and comorbiditiesA total of 104 patients were included: 52 with BAC and 52 without BAC (control group). The groups were deliberately constructed for comparative analysis and do not represent the prevalence of BAC. Patients with BAC were significantly older than those without BAC. The median age was 70.5 years in the BAC group and 62 years in the non-BAC group (p<0.001) (Table 1).
Diabetes mellitus and hypertension were significantly more prevalent in patients with BAC (p<0.001, p=0.026, respectively). Although cardiovascular diseases were more frequent in the BAC-positive group, the difference did not reach statistical significance (p=0.089). No significant differences were observed for cerebrovascular disease or other comorbidities (Table 2).
Carotid Doppler findings according to BAC presencePatients with BAC demonstrated significantly lower ICA PSV and ICA EDV compared with those without BAC (p<0.001 for both). In contrast, the RI was significantly higher in the BAC-positive group (p=0.034). There were no significant differences in common carotid IMT (p=0.331) or PI (p= 0.162) between groups (Table 1). Also, no association was found between BAC and carotid plaque (p=0.534).
Carotid Doppler findings according to BAC gradePatients were further stratified according to BAC severity (control, grade 1, grade 2, and grade 3), and carotid Doppler parameters were compared across groups. The median age increased significantly with higher BAC grade (p<0.001), with the highest values observed in grade 2 and grade 3 groups. ICA PSV was significantly lower in Grade 2 compared to controls (p<0.001), while ICA EDV decreased significantly in Grade 1 (p=0.033) and 2 (p<0.001). ICA RI showed a significant difference between the control group and BAC Grade 2 (p=0.033). However, comparisons involving the grade 3 BAC subgroup did not reach statistical significance in several parameters. No statistically significant differences were observed between BAC grades in CCA-IMT or ICA PI values. The detailed data are provided in Supplementary Table 1.
Logistic Regression Analysis Univariate and multivariate logistic regression analyses were performed to identify factors independently associated with the presence of BAC (Supplementary Table 2). Multivariate logistic regression analysis showed that increasing age was independently associated with an increased risk of BAC, with each additional year increasing the odds by 4% (OR 1.04, p=0.017). Diabetes mellitus emerged as the strongest predictor, increasing the risk by approximately 8-fold (OR 8.08, p<0.001), while hypertension was associated with a 3-fold increased risk (OR 2.86, p=0.005).
Among Doppler parameters, lower ICA PSV (OR 0.97, p=0.002) and EDV (OR 0.95, p=0.018) were significantly associated with increased BAC risk. In contrast, a higher ICA RI was associated with increased risk, with a 1.58-fold rise in BAC likelihood per unit increase (OR 1.58, p=0.031). These findings indicate that both cardiometabolic factors and carotid hemodynamic parameters are independently associated with the presence of BAC.

Discussion

The current study investigated the relationship between mammographically detected breast arterial calcification (BAC) and carotid Doppler parameters and clinical factors associated with BAC. Our findings demonstrated that BAC was independently associated with altered carotid hemodynamics, characterized by lower ICA flow velocities and a higher resistance index. In contrast, no independent association was observed between BAC and CCA-IMT or carotid plaque. Therefore, BAC may represent a mammographic signature of systemic vascular stiffness. BAC was also strongly associated with major cardiovascular risk factors, including advanced age, diabetes mellitus, and hypertension.
The hemodynamic changes may reflect the pathophysiological consequences of medial arterial calcification, as BAC represents calcium deposition in the medial layer of arterial walls.^6,13,14 Unlike intimal calcification, medial calcification usually does not lead to significant lumen narrowing; instead, it causes arterial stiffness. As arterial stiffness increases, vascular compliance decreases, which can reduce flow velocities and increase peripheral vascular resistance. These mechanisms may explain the lower ICA PSV, EDV, and higher RI values observed in patients with BAC. Therefore, BAC may be a radiographic manifestation of systemic vascular stiffening rather than a direct indicator of focal atherosclerotic plaque formation.
The prevalence of BAC is more commonly observed in older and postmenopausal women.^3,4,15 Consistent with these findings, our study demonstrated a significant increase in age with increasing BAC grades, reflecting the well-known association between BAC and aging. This observation is consistent with the cumulative nature of vascular calcification and further supports the potential use of BAC grading as a marker of vascular aging. In our study, two equal groups were formed for comparative analysis purposes based on the presence of BAC and do not represent the prevalence of BAC.
Various methods have been used to assess BAC in mammography, including binary classification (presence/absence) ^7,16 and visual scoring systems.^8,17,18 Recent advancements allow for more quantitative assessment using specialized software and artificial intelligence (AI) -based approaches.^19,20 However, training some AI models requires large patient groups and therefore takes a significant amount of time.²¹ In our study, we used a visual BAC scoring system described in the literature, based on the morphology and number of BAC.¹¹
Although BAC is classified as benign under the BI-RADS system,¹ increasing evidence highlights its clinical significance. Several studies have shown that BAC is associated with cardiovascular and cerebrovascular risk factors.[6,8–11] Many studies have reported consistent associations between BAC and high coronary artery calcification (CAC) scores.[3,4,23–25] Recent AI-based studies have demonstrated that both the presence and the quantitative burden of BAC are significantly and independently associated with major cardiovascular outcomes, stroke, and increased all-cause mortality.^19,20 Our findings are consistent with previous investigations indicating a relationship between BAC and cardiometabolic risk factors, such as advanced age, diabetes, and hypertension. The strong relationship between BAC and diabetes may be explained by medial artery calcification, which is more common in diabetic patients and causes arterial stiffness rather than luminal narrowing. Similarly, the independent association with hypertension supports the concept that BAC reflects systemic vascular remodeling and increased arterial stiffness.
Carotid Doppler ultrasonography is widely used for the non-invasive evaluation of vascular structure and hemodynamics. While many studies have reported increased CCA-IMT in BAC-positive patients,^3,6,8,9 Sarrafzadegan et al. have found no significant difference.¹⁰ Also, a study suggested that BAC reflects age-related vascular changes rather than direct atherosclerosis.¹⁷ In our study, BAC was not independently associated with carotid IMT or plaque presence. This finding may reflect the pathophysiological difference between medial calcification and intimal atherosclerosis, as IMT reflects intimal disease, whereas BAC represents medial calcification and arterial stiffness. Our findings support the hypothesis that these processes represent distinct vascular phenotypes.
The relationship between BAC and carotid Doppler hemodynamics is not fully understood, and only a few studies have evaluated mammographic BAC in conjunction with carotid Doppler parameters. Büyükkaya et al. reported an association with increased CCA-IMT but no association with CCA Doppler flow parameters.⁸ In contrast, our study demonstrated significant ICA hemodynamic changes, including lower PSV and EDV and higher RI, despite no association with CCA-IMT. These findings suggest that ICA hemodynamic parameters may be more sensitive to vascular stiffness and distal vascular resistance than CCA measurements. This supports the concept that BAC is more closely associated with systemic vascular stiffness than with focal atherosclerotic stenosis. An increase in RI may indicate increased peripheral vascular resistance and impaired microvascular perfusion, thus contributing to cerebral hypoperfusion and an increased risk of cerebrovascular disease. Clinically, incidental detection of BAC during routine mammography may provide an opportunity for early cardiovascular risk identification without requiring additional imaging or cost.
Our study contributes to this limited literature and is among the first to specifically investigate the association between BAC and ICA Doppler indices, allowing detection of subtle hemodynamic changes associated with BAC. Unlike most prior studies that evaluated only CCA measurements, we assessed both structural (CCA-IMT) and functional (ICA flow) parameters, providing a more comprehensive understanding of vascular effects.

Limitations

This study has several limitations. First, it was a retrospective, single-center study with a relatively small sample size, particularly in the BAC grade 3 subgroup, which may have limited statistical power. Second, some cardiovascular risk factors, such as smoking status, lipid profile, and body mass index, were not consistently available due to the retrospective design, and long-term cardiovascular outcomes were not evaluated. Third, intra- and inter-observer variability between the radiologists could not be assessed. Finally, BAC was evaluated using a visual scoring system rather than automated quantitative methods, which may introduce observer variability.

Conclusion

In conclusion, BAC is associated with altered carotid hemodynamics and established cardiovascular risk factors such as advanced age, diabetes mellitus, and hypertension. Decreased internal carotid artery flow velocities and increased RI suggest that BAC reflects systemic arterial stiffness rather than intimal atherosclerosis and may serve as an opportunistic imaging biomarker for cardiovascular risk stratification. Further studies are needed to confirm these findings.

Declarations

Abbreviations

BAC: Breast arterial calcification
CDUS: Color Doppler Ultrasonography
CCA: Common Carotid Artery
IMT: Intima-media thickness
ICA: Internal Carotid Artery
PSV: Peak systolic velocity
EDV: End diastolic velocity
RI: Resistive index
PI: Pulsatile index
CAD: Coronary artery disease
CAC: Coronary artery calcification

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Received:

March 31, 2026

Published Online:

June 22, 2026