Milas M, Bush RL, Lin P, Brown K, Mackay G, Lumsden A, Weber C, Dodson TF, et al.
Journal of vascular surgery. Date of publication 2003 Mar 1;volume 37(3):501-7.
1. J Vasc Surg. 2003 Mar;37(3):501-7.
Calciphylaxis and nonhealing wounds: the role of the vascular surgeon in a
multidisciplinary treatment.
Milas M(1), Bush RL, Lin P, Brown K, Mackay G, Lumsden A, Weber C, Dodson TF.
Author information:
(1)Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio,
USA.
OBJECTIVE: Calciphylaxis, a disorder of calcium-phosphate metabolism that can
result in arterial calcification, skin and solid organ calcium deposits, and
nonhealing ulcerations, is associated with significant morbidity and mortality.
Although its most common cause is secondary hyperparathyroidism in patients with
renal failure, vascular surgeons are frequently called on to evaluate these
nonhealing extremity wounds. We reviewed our experience of a multidisciplinary
approach in treating patients with calciphylaxis and nonhealing ulcers.
PATIENTS AND METHODS: Over a 14-month period at a tertiary center, five patients
were seen with calciphylaxis and nonhealing leg wounds. Demographics, disease
characteristics, surgical treatment, and outcomes were analyzed.
RESULTS: All five patients were black women aged 40 +/- 8.9 years with
hypertensive renal failure undergoing long-term hemodialysis (80 +/- 43 months).
They had large, painful lower extremity wounds or necrotic ulcers (mean size, 135
cm(2)) that had developed over 2 to 4 months. Three patients had palpable pedal
pulses, one patient had Doppler pedal signals, and one patient had absent pedal
flow. Arteriogram was performed in the latter two patients, and one patient
underwent lower extremity revascularization because of superficial femoral artery
stenosis with symptomatic improvement. Four patients underwent aggressive
debridement by the vascular surgical service, and two needed plastic
surgeon-performed skin grafting. All patients had elevated parathyroid hormone
levels (mean, 1735 pg/mL; > 25 x normal level); mean preoperative calcium levels
were normal (10 mg/dL). After either subtotal (n = 4) or total (n = 1)
parathyroidectomy by an experienced endocrine surgeon, a significant reduction in
parathyroid hormone and calcium levels was seen (122 pg/mL and 7.9 mg/dL,
respectively; P <.05). There were no postoperative complications or amputations;
one patient died 12 months after parathyroidectomy of severe preexisting
cardiopulmonary disease. Complete wound healing was observed by 4.8 +/- 2 months.
During a mean follow-up period of 9 months (range, 1 to 18 months), all wounds
remained healed without ulcer recurrence.
CONCLUSION: The diagnosis of calciphylaxis should be considered in patients with
end-stage renal disease with atypical tissue necrosis or subcutaneous nodules.
Early recognition of calciphylaxis and multidisciplinary treatment, including
diligent wound care, frequent debridement, parathyroidectomy, and appropriate
skin grafting or revascularization, can result in improved wound healing and limb
salvage.
DOI: 10.1067/mva.2003.70
PMID: 12618682 [Indexed for MEDLINE]
