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Medical Student Research Case Reports

12 DELAYED ANGIOGRAPHIC TRANSIT TIME AS A DIAGNOSTIC INDICATOR IN CALCIPHYLAXIS: A CASE REPORT

Jash Patel, BS, OMS-II; Rathnakar M. Sherigar, MD; Devasmita C. Dev, MD Corresponding author: jpatel06@vcom.edu

VCOM-Virginia, Blacksburg, Virginia Salem Veterans Affairs Medical Center, Salem, Virginia

Context: Calciphylaxis is a rare but life-threatening vasculopathy characterized by medial arteriolar calcification, microvascular ischemia, and progressive tissue necrosis, most commonly seen in patients with end-stage kidney disease. Diagnosis is challenging, and functional imaging assessments are not well established. This case highlights the potential use of radiographic contrast transit time as an indicator of underlying microvascular compromise. Report of Case: A 73-year-old male dialysis patient presented with right lower extremity pain and clinical concern for limb ischemia. His past medical history was significant for chronic kidney disease and biopsy-confirmed calciphylaxis. Initial foot radiographs demonstrated extensive vascular calcifications, and abdominal CT imaging revealed additional arterial calcification within the aortoiliac circulation. Digital subtraction angiography (DSA) of the right lower extremity was subsequently performed. Three-vessel runoff to the foot was preserved; however, dissections with aneurysmal dilation of the right external iliac

artery were identified. A self-expanding stent and stent-graft were successfully deployed with anatomic improvement. Despite restored macrovascular patency, quantitative analysis demonstrated markedly prolonged contrast transit time from the femoral artery to the pedal vasculature—approximately 57.5 seconds. This delay persisted even after stent placement, indicating that the impaired perfusion was unlikely due to large-vessel obstruction. The imaging findings, combined with the patient’s clinical presentation and histopathologic confirmation, supported a diagnosis of calciphylaxis with severe microvascular dysfunction. Comments: Compared with values reported in the literature, the patient’s transit time was substantially prolonged. Color-coded DSA studies describe femoral to-pedal time-to-peak intervals of approximately 11.86 ± 4.26 seconds in patients with peripheral arterial disease, improving to 6.75 ± 2.03 seconds following revascularization. The nearly fivefold elevation in this patient suggests profound microvascular impairment distinct from macrovascular occlusion. Most imaging

modalities used in calciphylaxis—including radiographs and CT—assess only structural calcification. This case demonstrates that functional perfusion assessment via DSA transit time may reveal significant microvascular compromise not apparent with structural imaging alone. The coexistence of calciphylaxis with large-vessel abnormalities, including aneurysm and dissection in this case, raises the possibility that calciphylaxis may affect a broader spectrum of vascular pathology than traditionally appreciated. Diagnosis: Calciphylaxis with severe microvascular perfusion delay, evidenced by markedly prolonged angiographic contrast transit time. IRB Statement: Consent has been obtained from the patient to use their data for this case report.

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