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LETTER TO THE EDITOR
Year : 2020  |  Volume : 11  |  Issue : 3  |  Page : 218-219

Medial arterial calcification of dorsalis pedis artery in a diabetic foot: A poor prognostic feature


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission17-Apr-2020
Date of Decision03-Jun-2020
Date of Acceptance29-Jun-2020
Date of Web Publication1-Sep-2020

Correspondence Address:
Dr. Ganesh S Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOD.JOD_21_20

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How to cite this article:
Dharmshaktu GS. Medial arterial calcification of dorsalis pedis artery in a diabetic foot: A poor prognostic feature. J Diabetol 2020;11:218-9

How to cite this URL:
Dharmshaktu GS. Medial arterial calcification of dorsalis pedis artery in a diabetic foot: A poor prognostic feature. J Diabetol [serial online] 2020 [cited 2020 Oct 29];11:218-9. Available from: https://www.journalofdiabetology.org/text.asp?2020/11/3/218/294038



Dear editor,

Diabetic foot resulting from ischemia, neuropathy, and infection is a dreaded complication of long-standing uncontrolled diabetes mellitus (DM) and calls for dedicated care on part of patient and treating physician both. Medial wall calcification (MAC) of arteries is one finding, readily identified in radiographs as classical “pipe stem” or “tram track” calcification, that is found to correlate with severity and duration of DM in certain patients.[1] Diabetic cases seem to have more MAC than nondiabetic ones as found in one study regarding amputation in diabetic cases.[2] The presence of radiological calcification, thus should be reminder of cautious periodic review of patient to avoid untoward complications and we learned it hard way from a case that is described here.

A 68-year-old male patient with history of long-standing DM for the last 10 years had history of recurrent foot ulceration in the left side 5 year back for which multiple toe amputation was done. The left foot wound was well healed and showed no complication; however, there was radiological calcification in dorsalis pedis artery and its branches at that time for which careful sugar monitoring and regular follow-up was advised to the patient [Figure 1]A and [B]. Patient became negligent to regular follow-up after 1 year and was home treating his diabetes. He then presented 2 days back with history of recurrent ulceration of right great toe nonresponsive to multiple treatment and dressings. His great toe and fourth toe were undergoing gangrenous changes and blackening [Figure 1]C. The radiograph of right foot showed development of cortical irregularity of great toe suggestive of impending osteomyelitis along with calcification in the dorsalis pedis and its distal arteries [Figure 1]D. The color Doppler of the lower extremity showed arterial vasculopathy with significant stenosis and loss of peripheral resistance, whereas the venous study had normal flow and compressibility. The angiographic study of lower limb was refused by the patient. His uncontrolled diabetes required supervised insulin therapy and regular dressing to check further progression of diabetes and wound. As the gangrene halted at the same level but the toe had to be amputated after 5 months. This case snippet highlights importance of cautious prognosis explanation and regular follow-up to prevent development of recurrent ulceration.
Figure 1: The previous radiograph of the left foot, showing amputated toes and calcification of dorsalis pedis and first dorsal metatarsal artery (A) and the clinical image of the same with healed wounds and no current problem (B). The present right foot radiograph (C) showing great toe distal phalanx cortical irregularity and presence of medial arterial calcification of dorsalis pedis and distal branches (marked by arrow). The corresponding foot image showing blackening and wound mostly affecting great toe (D)

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In a radiological study of MAC cases, especially of first dorsal metatarsal artery, 93% cases have DM and all had impaired glucose tests.[3] This might serve as foot-at-risk sign in DM with high incidence of foot ulceration or future surgeries. The calcifications are also correlated to male gender, other cardiovascular risk factors, and peripheral neuropathy severity.[4] Baseline vascular calcification was high in renal compromise status in DM. Our case though had preserved renal status.[5] One fact of common clinical involvement in DM of crural arteries (tibials and peroneals) and relative sparing of foot arteries is distinguishing features from nondiabetics.[6] MAC has been associated with distal symmetric neuropathy and loss of certain neuropeptides might be important causative factor. The affliction of distal extremities in MAC also correlates to distal symmetric neuropathy.[7] Whether this phenomenon involves mere calcification or bone formation/ossification shall, however, be clear in future research. The lessons from this case underline importance of extracareful treatment of patients with radiological evidence of arterial calcification for frequent checkup, foot care, and strict blood sugar control to avoid a complicated diabetic foot.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Edmonds ME Medial arterial calcification and diabetes mellitus. Z Kardiol 2000;89:101-4.  Back to cited text no. 1
    
2.
Mozes G, Keresztury G, Kadar A, Magyar J, Sipos B, Dzsinich S, et al. Atherosclerosis in amputated legs of patients with and without diabetes mellitus. Int Angiol 1998;17:282-6.  Back to cited text no. 2
    
3.
Smith CD, Bilmen JG, Iqbal S, Robey S, Pereira M Medial artery calcification as an indicator of diabetic peripheral vascular disease. Foot Ankle Int 2008;29:185-90.  Back to cited text no. 3
    
4.
Bourron O, Aubert CE, Liabeuf S, Cluzel P, Lajat-Kiss F, Dadon M, et al. Below-knee arterial calcification in type 2 diabetes: Association with receptor activator of nuclear factor Kb ligand, osteoprotegrin and neuropathy. J Clin Endocrin Metabol 2014;11:4250-8.  Back to cited text no. 4
    
5.
de Vineusa SG, Ortega M, Mrtinez P, Goicoechea M, Campdera FG, Luno J Subclinical peripheral arterial disease in patients with chronic kidney disease: Prevalence and related risk factors. Kidney Int Suppl2005;67:S44-7.  Back to cited text no. 5
    
6.
Conrad MC Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease. Circulation 1967;36:83-91.  Back to cited text no. 6
    
7.
Jeffcoate WJ, Rasmussen LM, Hofbauer LC, Game FL Medial arterial calcification in diabetes and its relationship to neuropathy. Diabetologia 2009;52:2478-88.  Back to cited text no. 7
    


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