From Diabetic Foot Microvascular Disease to Medial Arterial Sclerosis and Calcification in Chronic Limb-Threatening Ischemia: A Potentially Unified Pathogenic and Prognostic Entity for Tissue and Limb Loss

Contemporary publications revealed that microvascular disease (mVD) represents a common, yet poorly controlled microcirculatory complication, currently encountered in the multifactorial diabetic neuro-ischemic foot pathology. The presence of mVD in vascular structures of < 100 μm was evoked to represent an independent detrimental pathogenic factor, leading to increased inferior limb major complications and limb loss. Convergently, medial artery sclerosis (MAS) and medial artery calcification (MAC) were described as closely affiliated pathological entities, equally encountered at the inferior limb level in diabetic patients. This review aims to provide updated information about the clinical and prognostic significance of peripheral diabetic mVD, studied apart, or in association with concomitant MAS and MAC. These three entities appear to represent rather interconnected stages of a unified pathological process inflicted by persistent hyperglycaemia, leading to specific structural and functional arterial damage and limb loss. Diabetic foot mVD necessitates an independent, systematic assessment, to identify patients with high limb loss prognostic.