Medial Arterial Calcification

NewsBot · Jun 21, 2016

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Medial Arterial Calcification
An Overlooked Player in Peripheral Arterial Disease
Chin Yee Ho, Catherine M. Shanahan
ATVBAHA.116.306717

Peripheral arterial disease (PAD) is a global health issue that is becoming more prevalent in an aging world population. Diabetes mellitus and chronic kidney disease are also on the increase, and both are associated with accelerated vascular calcification and an unfavorable prognosis in PAD. These data challenge the traditional athero-centric view of PAD, instead pointing toward a disease process complicated by medial arterial calcification. Like atherosclerosis, aging is a potent risk factor for medial arterial calcification, and accelerated vascular aging may underpin the devastating manifestations of PAD, particularly in patients prone to calcification. Consequently, this review will attempt to dissect the relationship between medial arterial calcification and atherosclerosis in PAD and identify common as well as novel risk factors that may contribute to and accelerate progression of PAD. In this context, we focus on the complex interplay between oxidative stress, DNA damage, and vascular aging, as well as the unexplored role of neuropathy.
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NewsBot · Aug 31, 2018

Prevalence of Lower-Extremity Arterial Calcification in Patients with Diabetes Mellitus Complicated by Foot Disease at an Urban US Tertiary-Care Center.
Vanessa Cardenas, Kyung Seo, Shyam Sheth, and Andrew J. Meyr (2018)
Journal of the American Podiatric Medical Association: July 2018, Vol. 108, No. 4, pp. 267-271.

Background: We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system.

Methods: The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections.

Results: Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity.

Conclusions: The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.
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NewsBot · Feb 15, 2021

Evaluating the Impact of Medial Arterial Calcification on Outcomes of Infrageniculate Endovascular Interventions for Treatment of Diabetic Foot Ulcers
Jennifer Skolnik et al
Vasc Endovascular Surg. 2021 Feb 12

Background: Medial arterial calcification (MAC) of the tibial and pedal arteries has been associated with an increased risk of amputation among people with diabetes. Endovascular interventions on infrageniculate vessels are frequently performed with the intent of treating peripheral artery disease (PAD) and decreasing the risk of amputation in those with diabetes. This study aimed to investigate how the extent of MAC impacts outcomes of endovascular procedures in people with diabetic foot ulcers (DFU).

Methods: We identified all patients who had undergone infrageniculate angioplasty in the setting of DFU at our institution between 2009 and 2019. Subjects were assigned a MAC score based on the severity of MAC in each vessel visualized on plain radiographs of the ankle and foot. We evaluated the relationship between MAC and the primary outcome, major adverse limb event (MALE), using stratified Cox proportional modeling.

Results: Among 99 subjects with DFU who had undergone infrageniculate angioplasty, MALE occurred in 50% (95% confidence interval [CI] 38%-61%) of patients within 1 year of intervention. On univariate Cox regression analysis, each 1 point increment in MAC score (hazard ratio [HR], 1.09; 95% CI 1.01-1.18), the third tertile of MAC score (HR, 2.27; 95% CI 1.01-5.11), age (HR 0.96; 95% CI 0.93-0.99), and wound grade (HR, 5.34; 95% CI 2.17-13.14), were significantly associated with increased risk of MALE. On adjusted analysis stratified by wound grade, MAC score was found to be associated with MALE only in patients with a low wound grade.

Conclusion: Increased severity of MAC is associated with increased risk of MALE for subjects undergoing infrageniculate angioplasty with a low wound grade. Further research is needed to better understand the complex relationships of MAC, PAD, DFU, and interventions aimed at promoting healing of DFU.
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NewsBot · May 31, 2021

The Influence of Arterial Calcification on Clinical Outcomes in Patients with Diabetic Foot Ulcer Complicated by Osteomyelitis Treated by Surgery
Marta Carmena-Pantoja et al
Int J Low Extrem Wounds. 2021 May 28

The aim of our study was to analyze the influence of radiographic arterial calcification (RAC) on clinical outcomes and wound healing in patients with diabetic foot ulcers complicated by osteomyelitis treated by surgery. We analyzed retrospectively the clinical records of 102 patients with diabetic foot osteomyelitis who underwent surgery at a specialized diabetic foot unit between January 2014 and December 2016. The clinical data of evolution until its complete epithelialization and a follow-up 1 year were reviewed, and after reviewing the radiological images, patients were classified into 2 groups: those with RAC and those without RAC. We analyzed several clinical features in both groups. The presence of RAC was associated with a greater time of healing (10.68 ± 7.24 vs 8.11 ± 4.50 weeks; P = .029) and shorter time to recurrence and reulceration (13.30 ± 9.25 vs 18.81 ± 11.63 weeks; P = .036). However, this association was not found for patients with mild and moderate peripheral artery disease (PAD), whose time of healing was 8.97 ± 4.51 weeks compared to 9.16 ± 6.39 weeks for patients without PAD; P = .864. The time of healing of diabetic foot ulcers complicated by osteomyelitis treated by surgery can be negatively affected by the presence of RAC even more than by the presence of mild and moderate ischemia. The presence of RAC may offer clinical guidance at the level of primary care though this would need thorough validation in future studies.
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NewsBot · Sep 7, 2021

Pedal arterial calcification score is associated with risk of major amputation in chronic limb-threatening ischemia
Iris H Liu et al
J Vasc Surg. 2021 Sep 2;S0741-5214(21)01978-9

Objective: The medial arterial calcification (MAC) score is a simple metric that describes the burden of inframalleolar calcification based on plain foot x-ray. We hypothesize that higher MAC score is independently associated with risk of major amputation in patients with chronic limb threatening ischemia (CLTI).

Methods: This is a single-institution retrospective study of 250 patients who underwent infrainguinal revascularization for CLTI between 1/2011 and 7/2019 and had foot x-rays available for MAC score calculation. A single blinded reviewer assigned MAC scores of 0-5 based on two-view minimum plain foot radiographs, with 1 point each for calcification of > 2 cm in the dorsalis pedis, plantar and metatarsal arteries and > 1 cm in the hallux and non-hallux digital arteries.

Results: The MAC score distribution was 0 (36%), 1 (5.2%), 2 (8.4%), 3 (14%), 4 (14%) and 5 (21%). The MAC score was trichotomized to facilitate analysis and for clinical utility [mild (0-1), moderate (2-4), severe (5;)]. Variables independently associated with higher MAC score were male sex, diabetes, end-stage renal disease (ESRD), and the Global Limb Anatomic Staging System (GLASS) pedal score. The MAC score did not associate with the Society for Vascular Surgery Wound, Ischemia, foot Infection (SVS WIfI) grades or overall WIfI stage (p=0.58). Median follow-up was 759 days (IQR 264-1541). Higher MAC score was significantly associated with risk of major amputation (p<0.0001). In a Cox Proportional Hazards multiple regression model for major amputation including the trichotomized MAC score, diabetes, ESRD and WIfI stage (1-3 vs. 4); the MAC score [MAC 5: p=0.001, HR 4.9 (1.9-13.1); MAC 2-4: p=0.01, HR 3.4 (1.3-8.8)] and WIfI stage [WIfI 4: p=0.03, HR 2.1 (1.1-3.9)] were significantly associated with major amputation. In subsets of patients with the most advanced WIfI stages of 3-4 (191/250; 76%) and in patients with diabetes (185/250; 74%), MAC further stratified risk of major amputation in univariate and multivariate analyses.

Conclusions: The MAC score is a simple, practical tool and a strong independent predictor of major amputation in patients with CLTI. It provides novel clinical data that are currently unmeasured in any validated CLTI staging system. The MAC score is a promising standardized measure of inframalleolar disease burden that may be used in conjunction with the current WIfI staging system to help improve outcomes stratification and determine optimal treatment strategies for patients with CLTI.
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NewsBot · Oct 13, 2021

Approximation of the Ankle-Brachial Index in the Setting of Medial Arterial Calcific Sclerosis
Andrew J. Meyr et al
September 08, 2021

The presence of medial arterial calcific sclerosis is known to cause inaccuracy in the interpretation of noninvasive vascular testing. This substantially limits the utility of an important baseline diagnostic test for peripheral arterial disease. Therefore, the objective of this investigation was to derive a method to effectively factor out calcification in the interpretation of the ankle and digital brachial indices. The noninvasive vascular testing results of 160 subjects were stratified into the absence of calcification, mild calcification, moderate calcification, and severe calcification based on plain film radiographic findings of the infrageniculate vessels. Measurements were then performed of the pulse volume recording (PVR) waveforms at brachial, ankle and digital anatomic levels to include PVR wavelength and PVR upstroke length, with a calculation of the ratio of PVR upstroke length to PVR wavelength. These measurements were compared between groups and then correlated to the ankle and digital brachial indices. A significant difference was observed in the PVR upstroke ratio between the 3 anatomic levels (0.1818 vs 0.2622 vs 0.3191; p < .001), but not between the 4 calcification groups (0.2457 vs 0.2363 vs 0.2694 vs 0.2631; p = .242). A significant negative correlation was observed between the PVR upstroke ratio and the ankle brachial index (ABI) (Pearson -0.454; p = .002) with linear regression indicating the relationship is defined by the formula: Effective ankle brachial index = 1.17 – (1.33 × PVR upstroke ratio at ankle level). A significant negative correlation was also observed between the PVR upstroke ratio and the digital brachial index (Pearson -0.553; p < .001) with linear regression indicating the relationship is defined by the formula: Effective toe brachial index = 1.04 – (1.61 × PVR upstroke ratio at digital level). The results of this investigation demonstrate the feasibility of, and provide equations to approximate, the effective ankle brachial and toe brachial indices in the setting of medial arterial calcification.
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NewsBot · Jan 23, 2023

The predictive value of vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus
Toby Jennison et al
Foot Ankle Surg. 2023 Jan 9;S1268-7731(23)00003-6

Introduction: There are nearly 500,000 people with undiagnosed diabetes mellitus in the UK. A common complication of diabetes is vascular calcification. The incidental finding of vascular calcification on plain radiographs in patients with undiagnosed diabetes has the potential to alter patient management. We hypothesised that the presence of vascular calcification on plain radiographs of the foot may predict the diagnosis of diabetes and aimed to determine the positive predictive value of vascular calcification to diagnose diabetes.

Methods: A retrospective case control study compared 130 diabetic patients to 130 non-diabetic patients that were matched for age and gender. The presence of vascular calcification in anterior, posterior or plantar vessels was measured on plain radiographs. McNemar's Chi-squared test and positive predictive values were calculated. Conditional logistic regression models estimated the association between calcification and diabetes RESULTS: The overall mean age was 58.0 % and 31.5 % were females. 89.2 % of those with diabetes had calcification present, and 23.1 % in those who did not have diabetes had calcification. McNemar's test for independence gives p < 0.001. Calcification in both anterior and posterior vessels predicts diabetes with a positive predictive value of 91.2 % (95 % CI 76.9-97.0 %). The odds ratio for having diabetes is 78 (95 % CI: 7.8 - 784) times higher in a person who has calcification in the blood vessels of their ankle than in a person without calcification after adjusting for confounders CONCLUSION: This study has demonstrated that vascular calcification in the anterior and posterior blood vessels is over 90 % predictive of a diagnosis of diabetes. This screening test could be used in future clinics when interpreting radiographs, aiding in the diagnosis of diabetes and altering patient management.
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NewsBot · Jan 24, 2023

The predictive value of vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus
TobyJennison et al
Foot and Ankle Surgery; 9 January 2023

Introduction
There are nearly 500,000 people with undiagnosed diabetes mellitus in the UK. A common complication of diabetes is vascular calcification. The incidental finding of vascular calcification on plain radiographs in patients with undiagnosed diabetes has the potential to alter patient management. We hypothesised that the presence of vascular calcification on plain radiographs of the foot may predict the diagnosis of diabetes and aimed to determine the positive predictive value of vascular calcification to diagnose diabetes.

Methods
A retrospective case control study compared 130 diabetic patients to 130 non-diabetic patients that were matched for age and gender. The presence of vascular calcification in anterior, posterior or plantar vessels was measured on plain radiographs. McNemar’s Chi-squared test and positive predictive values were calculated. Conditional logistic regression models estimated the association between calcification and diabetes

Results
The overall mean age was 58.0 % and 31.5 % were females. 89.2 % of those with diabetes had calcification present, and 23.1 % in those who did not have diabetes had calcification. McNemar’s test for independence gives p < 0.001.

Calcification in both anterior and posterior vessels predicts diabetes with a positive predictive value of 91.2 % (95 % CI 76.9–97.0 %).

The odds ratio for having diabetes is 78 (95 % CI: 7.8 – 784) times higher in a person who has calcification in the blood vessels of their ankle than in a person without calcification after adjusting for confounders

Conclusion
This study has demonstrated that vascular calcification in the anterior and posterior blood vessels is over 90 % predictive of a diagnosis of diabetes. This screening test could be used in future clinics when interpreting radiographs, aiding in the diagnosis of diabetes and altering patient management.
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NewsBot · Apr 11, 2023

Foot Dorsal and Plantar Flexion to Enhance Crossing of Tortuous Highly-Calcific Ankle Vessels During Lower Limb Revascularization Procedures: A Technical Note
Roberto Gandini et al
Cardiovasc Intervent Radiol. 2023 Apr 11.

Source

Purpose: To describe a crossing technique of stenotic/occluded and tortuous highly calcific ankle vessels during complex percutaneous limb salvage intervention in diabetic patients with ischaemic foot ulcers (Rutherford 5 and 6).

Technique: We propose a simple technique to achieve "straightening" of the tortuous vessel and allow safe devices passage into the foot arteries, Patients were asked to hold their foot in plantar or dorsal flexion, accordingly to the treated artery. If unable to do so, an equipe member executed the manoeuvre on their behalf.

Results: The technique was applied in 148 cases, with a success rate of 81% (120/148). No complications related to the manoeuvre were observed.

Conclusion: Crossing of tortuous distal crural vessels can be challenging in diabetic patients; in our experience, this technique can be a useful tool to obtain a successful recanalization in complex procedures with high risk of failure.
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NewsBot · Jun 5, 2023

Medial Arterial Calcification and the Risk of Amputation of Diabetic Foot Ulcer in Patients With Diabetic Kidney Disease
Joon Myeong So et al
J Korean Med Sci. 2023 May 29;38(21):e160.

We assessed the risk factors for major amputation of diabetic foot ulcers (DFUs) in patients with diabetic kidney disease (DKD) stages 3b-5. For DFU assessment, in addition to DFU location and presence of infection, ischemia, and neuropathy, vascular calcification was assessed using the medial arterial calcification (MAC) score. Of 210 patients, 26 (12.4%) underwent major amputations. Only the location and extension of DFU, represented by Texas grade differed between the minor and major amputation groups. However, after adjusting for covariates, ulcer location of mid- or hindfoot (vs. forefoot, odds ratio [OR] = 3.27), Texas grades 2 or 3 (vs. grade 0, OR = 5.78), and severe MAC (vs. no MAC, OR = 4.46) was an independent risk factor for major amputation (all P < 0.05). The current use of antiplatelets was a possible protective factor for major amputations (OR = 0.37, P = 0.055). In conclusion, DFU with severe MAC is associated with major amputation in patients with DKD.
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NewsBot · Aug 8, 2023

Mönckeberg's Medial Calcific Sclerosis Makes Traditional Arterial Doppler's Unreliable in High-Risk Patients with Diabetes
Mehmet A Suludere et al
Int J Low Extrem Wounds. 2023 Jul 31;15347346231191588

Objective: To assess Mönckeberg's medial calcific sclerosis (MMCS) severity in patients with a diabetic foot infection.

Methods: This was an analysis of 2 randomized clinical trials in which we evaluated the treatment of 233 patients admitted to the hospital for moderate and severe foot infections. Arterial calcification was defined as visible radiopaque arteries on foot and ankle radiographs, recorded as the most distal visible artery involved (toes, metatarsals, and ankle/hindfoot).

Results: Most subjects (57.1%, n = 133) had MMCS, with extension to toes in 79 (59.4%), to metatarsals in 32 (24.1%), and to ankle/hindfoot in 22 patients (16.5%). In 7 patients (5.2%) MMCS was solely seen in dorsalis pedis (DP) artery, in 13 patients (9.8%) in posterior tibialis (PT) artery, and in 113 patients (85.0%) MMCS was seen in both arteries. Only 29.2% (n = 68) of DP arteries and 34.8% (n = 81) of PT arteries were not compressible by Doppler. DP and PT arteries were not compressible more often in MMCS (DP 34.3% vs 20.4%, P = .02 and PT 43.1% vs 21.4%, P < .01), toe-brachial indices of ≥0.7 were significantly more common in people without MMCS (46.0% vs 67.4%, P < .01). In contrast, there were no differences in skin perfusion pressure measurements (>50 mmHg; 67.7% vs 68.0%, P = .96), waveforms (biphasic/triphasic 83.5% vs 77.0%, P = .22), and pulse volume recording (9.6 ± 3.3 vs 13.7 ± 36.0) between patients with and without MMCS.

Conclusion: MMCS is common in patients with diabetic foot infections. MMCS is associated with noncompressible arterial Doppler studies and likely interferes with the accuracy of arterial Doppler studies.
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NewsBot · Aug 8, 2023

Medial Arterial Calcification Score is Associated with Increased Risk of Major Limb Amputation
Alexander D DiBartolomeo et al
J Vasc Surg. 2023 Jul 30

Objective: The pedal Medial Arterial Calcification (MAC) score has been associated with risk of major limb amputation in patients with chronic limb threatening ischemia. This study aimed to validate the pedal MAC scoring system in a multi-institutional analysis to validate its usefulness in limb amputation risk prediction.

Methods: A multi-institution, retrospective study of patients who underwent endovascular or open surgical infrainguinal revascularization for chronic limb threatening ischemia was performed. MAC scores of 0-5 were assigned based on visible calcified arteries on foot x-ray then trichotomized (0-1, 2-4, 5) for analysis. The primary outcome was major limb amputation at 6 months. Adjusted Kaplan-Meier models were used to analyze time-to-major amputation across groups.

Results: There were 176 patients with 184 affected limbs (mean of 66 years old, 61% male, 60% white), of which 97% presented with a wound. The MAC score was 0 in 41%, 1 in 9%, 2 in 13%, 3 in 11%, 4 in 13%, and 5 in 13% of the limbs. There were 26 (14%) major amputations and 16 (8.7%) deaths within 6 months. Patients with MAC 5 had a significantly higher risk of major limb amputation than both the 0-1 and 2-4 groups (p=0.001, p=0.044, respectively), and lower overall amputation-free survival (log-rank p=0.008).

Conclusions: Pedal MAC score is a reproducible and generalizable measure of inframalleolar arterial disease that can be used with Wound, Ischemia, and foot Infection staging to predict major limb amputation in patients with chronic limb threatening ischemia.
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NewsBot · Aug 11, 2023

Mönckeberg's medial calcific sclerosis in diabetic and non-diabetic foot infections
Mehmet A Suludere et al
Wound Repair Regen. 2023 Jul-Aug;31(4):542-546

The aim of this study was to evaluate the prevalence and extent of lower extremity Mönckeberg's Medial Calcific Sclerosis (MMCS) in patients with and without diabetes in patients admitted to the hospital for foot infections. This study retrospectively reviewed 446 patients admitted to the hospital with a moderate or severe foot infection. We defined diabetes based on ADA criteria and reviewed electronic medical records for demographics, medical history and physical examination data. Anterior-posterior and lateral foot radiographs were examined to identify the presence and extent of vascular calcification. We categorised MMCS based on anatomical location: ankle joint to the navicular-cuneiform joint, Lis Franc joint to metatarsophalangeal joints and distal to the metatarsophalangeal joints. The prevalence of MMCS was 40.6%. The anatomic extent of MMCS was 19.3% in the toes, 34.3% in the metatarsals and 40.6% in the hindfoot/ankle. Calcification was not common solely in the dorsalis pedis artery (DP) (3.8%) or solely in the posterior tibial artery (PT) (7.0%). Usually, both DP and PT arteries were affected by MMCS (29.8%). The prevalence of MMCS was higher in people with diabetes (in hindfoot and ankle [50.1% vs. 9.9%, p ≤ 0.01]; metatarsals [42.6% vs. 5.9%, p ≤ 0.01]; and toes [23.8% vs. 4.0%, p ≤ 0.01]). People with diabetes were 8.9 (CI: 4.5-17.8) times more likely to have MMCS than those without diabetes. This is a group that often has poor perfusion and needs vascular assessment. The high prevalence of MMCS raises questions about the reliability of the conventional segmental arterial Doppler studies to diagnose PAD.
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NewsBot · Jan 15, 2024

Leg dystrophic calcification as a consequence of chronic diabetic foot infection: a case report
Ariana Maia et al
J Wound Care. 2024 Jan 2;33(1):66-71

Foot ulceration and infection is associated with a substantial increase in morbidity and mortality in patients with diabetes. We present a clinical case of recurrent diabetic foot infection with an atypical clinical evolution. A 58-year-old male patient with type 1 diabetes and a history of bilateral Charcot foot neuroarthropathy was followed at our Diabetic Foot Clinic for an unhealed plantar foot ulcer for >1.5 years with recurrent episodes of infection. He was admitted to hospital due to foot ulcer reinfection with sepsis and ipsilateral lower limb cellulitis. The foot infection was found to be associated with an underlying abscess in the anterior compartment of the leg, with a cutaneous fistulous course with extensive alterations of an inflammatory nature. Exudate from the lesion was drained and tissue biopsied, revealing Serratia marcescens and Klebsiella oxytoca with dystrophic calcification (DC). Surgical excision of dystrophic tissue with debridement of the fistulous tracts was performed. The excised material corroborated the presence of fibroadipose connective tissue with marked DC, as well as areas of mixed inflammation compatible with a chronic infectious aetiology. Targeted long-term antibiotic therapy was implemented, for a total of six weeks, with a favourable clinical evolution and complete closure of the lesion at the final follow-up. DC results from calcium deposition in degenerated tissues without evidence of systemic mineral imbalance and is a potential cause of non-healing ulcers. Few cases of DC have been reported in diabetic foot patients and its treatment remains challenging and controversial. A longer follow-up period is necessary to verify the effectiveness of our approach.
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NewsBot · Apr 11, 2024

Pedal medial arterial calcification in diabetic foot ulcers: A significant risk factor of amputation and mortality
Lihong Chen et al
J Diabetes. 2024 Apr;16(4):e13527

Aims: Pedal medial arterial calcification (MAC) is frequently observed in individuals with diabetic foot ulcers (DFUs). However, the impact of pedal MAC on individuals with DFUs remains uncertain. The main aim of this study was to evaluate the association between pedal MAC with amputation and mortality outcomes.

Methods: A prospective, observational cohort study was conducted at West China Hospital from January 2012 to December 2021. Logistic regression analyses, Kaplan-Meier survival method, and Cox proportional hazards models were employed to evaluate the relationship between pedal MAC and amputation as well as mortality.

Results: A total of 979 patients were enrolled in the study. Peripheral artery disease (PAD) was observed in 53% of patients with DFUs, and pedal MAC was found in 8%. Over a median follow-up of 46 (23-72) months, foot amputation was performed on 190 patients, and mortality occurred in 246 patients. Pedal MAC showed a significant association with amputation both in unadjusted analysis (odds ratio [OR] = 2.98, 95% confidence interval [CI] = 1.86-4.76, p < .001) and after adjusting sex, age, albumin levels, hemoglobin levels, and diabetic retinopathy status (OR 2.29, 95% CI 1.33-3.93, p = .003). The risk of amputation was found to be twofold higher in individuals with PAD and pedal MAC compared to those with PAD alone (OR 2.05, 95% CI 1.10-3.82, p = .024). Furthermore, the presence of pedal MAC was significantly associated with an increased risk of mortality (p = .005), particularly among individuals with DFUs but without PAD (HR 4.26, 95% CI 1.90-9.52, p < .001), rather than in individuals presenting with both DFUs and PAD.

Conclusion: The presence of pedal MAC is significantly associated with both amputation and mortality in individuals with DFUs. Moreover, pedal MAC could provide additional value to predict amputation other than PAD.
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