For a generation we have taught a comforting rule. When the ankle lies — when Mönckeberg sclerosis stiffens the tibials and the ABI floats absurdly past 1.4 — go to the toe. The digital arteries, we said, are spared. The toe is the sanctuary. A new paper in JVS-Vascular Insights from Rutger Welling, Olaf Bakker and colleagues in Nieuwegein — with our friend Roberto Ferraresi among the authors — makes the case that the sanctuary was never quite as safe as we told ourselves. We escaped the ankle’s false floor and quietly built a smaller one under the hallux.
This is the natural sequel to the long arc we traced from Mönckeberg’s 1903 autopsy to today’s foot film, and to our 2024 look at toe pressures and medial arterial calcification.
What they found
A single-center retrospective of 494 limbs in 382 patients, every one with a toe pressure and a foot X-ray. Digital artery calcification (DAC) was present in 28.9% — not a rare bird. Those limbs carried a 2.5-fold hazard for one-year major adverse limb events (HR 2.51, 95% CI 1.68–3.73), and one-year MALE-free survival of 62.5% versus 83.3% in the uncalcified. After propensity matching 98 against 98 — where the calcification was essentially the only thing that differed — the calcified limbs went on to revascularization, amputation, or death far more often.
The number you can use Monday morning as a pro-tip
They plotted each limb’s calculated one-year MALE probability against its measured toe pressure. For any given level of risk, the calcified curve sat 20–30 mmHg higher than the uncalcified one. A calcified toe, in other words, needs 20–30 extra mmHg of measured pressure to be as “safe” as a clean one. So the authors’ pragmatic advice — and Olaf’s one-line summary when he flagged this for me — is exactly this:
When medial arterial calcification shows on the foot film, subtract 20–30 mmHg from the toe pressure before you let it reassure you.
That is a bedside correction factor, not a new machine. We like those.
A few things that keep us honest
The toe-brachial index did not rescue the situation — TP and TBI discriminated almost identically (AUC 74.4% vs 73.3%, not significant). And there was a provocative U-shape: pressures above 150 mmHg carried more events than the 120–150 band, hinting at an upper-limit artifact, though the numbers there are small. This all rhymes with our Are We Flying Blind? piece — our chairside tests wobble badly in MAC-prone patients. This paper names a mechanism and hands us a partial fix.
Where it points
Where it points is where the field is already converging, and where Roberto has been pushing us: no single chairside number is enough. Combine the pressure, the calcification burden on the film — the Ferraresi/Milan MAC score and the UCSF pedal calcification work, our collective work with Kate McGinigle and crew from UNC— and the waveform. That last bucket is exactly the territory of pedal acceleration time and optical perfusion — measures that do not depend on a compressible artery. It is the same distribution-not-just-transmission, SAD-and-MAC story Roberto told in Bremen that became our fractals post.
The toe remains a fine first-line tool. We just have to stop pretending it is incorruptible. When the film shows calcium, read the number 20–30 mmHg lower than it claims.
h/t Olaf Bakker for the heads-up from Nieuwegein, and congratulations to Rutger Welling and the whole team — Roberto Ferraresi, Andrej Schmidt, Daniel van den Heuvel, and Gert Jan de Borst.
Welling RHA, van den Heuvel DAF, Schmidt A, Ferraresi R, de Borst GJ, Bakker OJ. Toe Pressure Measurement in the Context of Digital Artery Calcification. JVS-Vascular Insights. 2026. doi:10.1016/j.jvsvi.2026.100429.
#DiabeticFoot #PAD #CLTI #ToePressure #ToeBrachialIndex #Calcification #MAC #MedialArterialCalcification #DigitalArteryCalcification #LimbPreservation #ActAgainstAmputation #VascularSurgery #JVSVascularInsights
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