The Unique Complexities Faced in the Treatment of Calciphylaxis 

Introduction: Calciphylaxis, also known as calcific uremic arteriolopathy, is a rare disease most often found in patients with end-stage renal disease. Cutaneous arteriolar calcification and subsequent tissue ischemia and infarction cause painful skin lesions and necrotic wounds. For patients who have failed wound care management of calciphylaxis, there is a need for adaptive methods that support soft tissue coverage and tissue infill to aid in skin graft success. This case report investigates the utilization of multiple plastic surgical and wound management methods for optimal outcome of complicated calciphylaxis cases.    Methods:A 74-year-old female with significant comorbidities including TAVR, CAD (status post angioplasty), PAD, carotid stenosis, DM, HTN, ESRD on HD presented with significant calciphylaxis wounds to the left lower extremity with associated osteomyelitis of the tibia. Following surgical irrigation and excisional debridement, morcellized OFM was applied to encourage granulation tissue formation. Partial surgical wound closure was also achieved. Subsequent wound management included NPWT, edema management, and bedside wound debridement. Successful wound granulation tissue was achieved, and the patient underwent staged involved local flap and skin grafting to her wounds.    Results:There was a 70% take of skin graft to the lower limb with 30% loss of graft at distal areas of arterial inflow disease.  The patient underwent successful drug coated balloon stent placement to the left CFA and has shown improved healing of the distal wounds. Patient has full remission of calciphylaxis and no signs of sepsis. She has entered a rehabilitation hospital and is undergoing comprehensive wound management with NPWT. There was no loss of motor function of the limb.   Discussion: Calciphylaxis poses unique challenges to wound care practitioners and plastic surgeons due to the high failure rates of non-operative treatment. It is common for calciphylaxis patients to develop sepsis, giving it a high mortality rate. Surgical intervention may be essential once the eschars become infected to prevent further tissue loss. Usage of multiple modalities should therefore be considered for the best chance of wound healing in patients, including consideration of CAMPs* for generating optimal soft tissue infill.  * CAMPs- cellular, acellular and matrix like productsReferences:Mayo Foundation for Medical Education and Research. (2022, September 3). Calciphylaxis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/calciphylaxis/symptoms-causes/syc-20370559#:~:text=Calciphylaxis%20(kal%2Dsih%2Dfuh,that%20can%20lead%20to%20death. Westphal, S. G. (2023, August 8). Calciphylaxis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519020/