Diffuse arterial calcification is characteristic of peripheral arterial disease, (PAD) particularly in diabetics. In diabetics, the rates of PAD and the more advanced forms of vascular disease such as critical limb ischemia (CLI) are higher and vascular intervention is known to be more difficult and less effective. For one in six patients, below knee amputations can result from microvascular disease without traditional peripheral arterial disease. Microvascular disease occurs in vessels with a diameter around 100 µm and is most commonly present in diabetic patients. Calciphylaxis is a life threatening complex disorder that presents with painful ischemic skin lesions caused by occlusion of blood vessels in subcutaneous fat and dermis. Mönckberg’s Arteriosclerosis results in extensive calcium deposits in the tunica media without obstruction into the lumen. This case highlights a young diabetic patient with rapidly progressing acute onset ulcers of the bilateral lower extremities status-post beginning peritoneal dialysis.
The patient underwent upper and lower arterial non-invasive studies, angiogram, computerized tomography angiography and punch biopsy.
The arterial duplex exams were normal with the exception of non-compressible calcified vessels. Microvascular disease was correlated with angiogram. CTA findings were conclusive for calciphylaxis and Mönckberg’s arteriosclerosis. Punch biopsy was performed to confirm calciphylaxis and patient was started on the appropriate treatment regimen. Unfortunately, limb salvage was not possible and amputations was ultimately performed.
There are other vascular pathologies that are not associated with traditional large artery atherosclerosis, such as calciphylaxis and Mönckberg’s arteriosclerosis. Even with seemingly normal arterial testing, the prognosis can be catastrophic. Although rare, these additional disease processes should be considered in dialysis patients with acute ulcerations.
Christina Fields, Heart and Vascular Sonographer, The Christ Hospital