Medial Arterial Calcification in Diabetic Foot Ulcer Management
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To the Editor: I commend Dr. Skolnik for highlighting medial arterial calcification (MAC) as an often-overlooked, yet critical factor in the prognosis and management of diabetic foot ulcers (DFUs). The article effectively underscores the limitations of ankle-brachial index (ABI) testing in patients with MAC and the prognostic value of radiographic calcification scoring.1
In my clinical experience in wound care, I have observed that Monckeberg’s arteriosclerosis is frequently detected incidentally on plain film radiographs obtained for foot ulcer evaluation or in suspicion of osteomyelitis. Unfortunately, its significance is often underappreciated, leading to missed opportunities for timely vascular referral.1 The correlation between MAC severity and poor limb preservation; particularly the higher rates of persistent ischemia and major amputation despite technically successful revascularizations, reinforces the need for proactive intervention.2
I believe incorporating MAC scoring into standard DFU assessment protocols could help bridge the gap between imaging findings and actionable care pathways, especially in diabetics, individuals with systemic lupus erythematosus, chronic kidney disease, in rare cases with vitamin D hypervitaminosis, and patients with an ABI greater than 1.3. As the literature suggests, early identification of severe pedal MAC and elevated inflammatory markers such as CRP, IL-6, and TNF-alpha in these patients should trigger multidisciplinary engagement, including vascular specialists, endocrinologists, and wound care teams, to optimize glycemic control, manage phosphate balance, and consider revascularization strategies tailored to calcified vessels.3
Future studies could explore whether early MAC detection combined with targeted risk factor modification might reduce rates of ulcer recurrence and improve long-term limb preservation. Given the high prevalence of diabetes and its complications, a systematic approach to MAC assessment may prove as important to DFU outcomes as infection control and pressure offloading.3
Dr. Skolnik’s article serves as a timely reminder that MAC is more than a radiographic curiosity; it is a prognostic marker that should actively shape clinical decision making in podiatric practice.
Sincerely,
Sajjad Momenibigdeli, BSN, RN
Scholl College of Podiatric Medicine, Class of 2027
References
1. Everhart JE, Pettitt DJ, Knowler WC, Rose FA, Bennett PH. Medial arterial calcification and mortality in diabetes. Diabetes Care. 1988;11(1):35-40.
2. Niskanen L, Suhonen M, Siitonen O, Lehtinen J, Uusitupa MIJ. Medial artery calcification predicts cardiovascular mortality in patients with NIDDM. Diabetes Care. 1994;17(11):1252-1256.
3. Ferraresi R, Palena LM, Mauri G, et al. Pedal medial arterial calcification score as a predictor of major amputation in patients with critical limb ischemia. J Endovasc Ther. 2020;27(6):911-919.
