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Review Article | DOI: https://doi.org/10.31579/2641-0419/547
1Cardio-Vascular and Thoracic Surgery, CHU Sart-Tilman Hospital, University of Liège, Belgium.
2Vascular Surgery, AZSint Blasius Hospital, Dendermonde Belgium.
*Corresponding Author: Vlad Adrian Alexandrescu, Cardio-Vascular and Thoracic Surgery, CHU Sart-Tilman Hospital, University of Liège, Belgium.
Citation: Vlad A. Alexandrescu, Koen R. Deloose, Arnaud Kerzmann, (2026), 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, J Clinical Cardiology and Cardiovascular Interventions, 9(2); DOI:10.31579/2641-0419/547
Copyright: © 2026, Vlad A. Alexandrescu. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 December 2025 | Accepted: 13 January 2026 | Published: 22 January 2026
Keywords: diabetic foot; chronic limb-threatening ischaemia; diabetic neuropathy; wound healing; chronic hyperglycaemia; medial arterial sclerosis; medial arterial calcification; microvascular disease.
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.
ABI - ankle-brachial index;
AGEs - advanced glycation end-products;
ASL - arterial spin labeling;
BOLD - blood oxygenation level-dependent;
BTA - below-the-ankle;
BTK - below-the-knee;
CLTI - chronic limb-threatening ischaemia;
CT-scan - computed tomography scan.;
DPN - diabetic peripheral neuropathy;
DSA - digital subtraction angiography;
EAOD - end-artery occlusive disease;
EVUS - extravascular ultrasound;
IVUS - intravascular ultrasound;
MAC - medial artery calcification;
MAS - medial artery sclerosis;
MACE - major adverse cardiac events;
MALE - major adverse limb events;
MRI-ASL - magnetic resonance imaging-arterial spin labeling;
MRI-BOLD - magnetic resonance imaging-blood O2 level dependent;
mVD - micro-vascular disease;
NIRS - near-infrared spectroscopy
PAD - peripheral artery disease;
PET-scan - positron emission tomography;
ROS - reactive oxygen species;
SAD - small-artery disease;
SFDI - spatial frequency domain imaging;
SPECT-CT - single photon emission tomography;
SVD - small-vessel disease;
TcPO2 - trans-cutaneous oxygen pressure;
X-rays - plane radiography;
Diabetes mellitus is associated to progressive structural and functional impairment of the vascular system. Conventionally, the arterial network is divided into macrocirculation (vessels with a diameter greater than 100 μm), and microcirculation (vessels inferior to 100 μm diameter). Diabetic foot microangiopathy is a common but insufficiently monitored complication of persistent hyperglycaemia; it is essentially represented by irreversible medial arteriolar layer damage and by capillary destruction. Historically, the first description of degenerative alterations (sclerosis and calcifications) located in the medial arterial wall of small vascular structures is attributed to J.G. Mönckeberg in 1903. [1] It took several decades before medial arterial sclerosis (MAS) and the associated medial arterial calcifications (MAC) gained their well-deserved clinical relevance as key detrimental cardiovascular factors. [2] These two pathological entities appear to be strongly related to higher rates of major adverse cardiac events (MACE), [2] major adverse limb events (MALE), [2-4] and increased perioperative morbidity and mortality. [2-4]
From a contemporary perspective, MAS and MAC represent markers of severe systemic vascular disease distinct from atherosclerotic affliction. [2, 4] Medial arterial pathology is often associated with diabetes mellitus, macro- and microvascular chronic limb-threatening ischaemia (CLTI), the diabetic neuro-ischaemic foot syndrome, renal insufficiency, ageing, and various inflammatory diseases. [2-7]
Based on improved electron microscopic investigation, an original publication by LeCompte in 1955 [6] offered one of the earliest studies that clearly delineated the distinction between macro- and microangiopathic disease in ischaemic diabetic limbs. [6] The microvascular disease was attributed to arteriolar and capillary destruction, as was later corroborated by Goldenberg et al. [7] It is also important to mention the pioneering work of Pedersen and Olsen, [8] who in 1962 proposed an original definition of “small-vessel disease” (SVD) as a taxonomic vascular entity in the assessment of the diabetic neuro-ischaemic foot. [8]
More recently, diabetic foot microangiopathy has gained considerable attention in relation to tissue and limb preservation in CLTI—paralleling the diagnostic progress made in the better-recognised diabetic retinopathy, cardiomyopathy, and peripheral neuropathy. [3, 9]
The aim of this review is to provide updated information regarding the current clinical, pathogenic, and prognostic significance of diabetic microvascular disease (mVD), as well as its contemporary screening, diagnostic, and therapeutic options—particularly in the context of diabetic CLTI and associated MAS and MAC affecting the lower limbs.
Publication screening and data assembling.
A parallel search was conducted in the Medline database, supplemented by unrestricted online data exploration, to identify publications related to microangiopathy in the diabetic foot syndrome within the context of CLTI. This investigation focused particularly on relevant publications from the last two decades. Fourteen keywords were employed during the database search, such as: “chronic limb-threatening ischaemia, diabetic neuro-ischaemic foot, medial arterial sclerosis, medial arterial calcification, arterial calcification, diabetic foot microangiopathy, hyperglycaemia pathology, diabetic microvascular complications, pathophysiology of diabetic microcirculation, diabetic peripheral neuropathy, diagnostic of diabetic microangiopathy, treatment of diabetic microangiopathy, prognostic of diabetic vascular complications, and perspectives in diabetic microvascular disease.”
Protocol for data selection and analysis
Following a three stages approach, the location, approval, and analytical processes are briefly illustrated in Figure. 1.
The finally selected data were integrated into a narrative review format.
Figure 1. Flow diagram resuming the selection process. (a). Screening for publications matching the selected key-words; (b). Data selection and analysis focusing on original, fitting abstracts; (c). The finally appointed full-text, relevant papers for analysis.
Structural and Functional Aspects
From a morphological point of view, the human vasculature associates a wide range of perfusion structures whose diameter varies from 2 cm (the aorta) down to 5 μm (the distant capillaries) (Figure. 2). [3, 6, 9, 10]
Commonly, the macrocirculation assembles (Figure. 2) vessels with a diameter greater than 100 μm, while the microcirculation refers to the kilometric “ubiquitarian” vascular network that associates different types of arterioles, capillaries, and venular conduits, whose diameter varies between 100 μm and 5 μm. [3, 9, 10]
The microcirculatory conduits exhibit a specific histological wall arrangement, intimately adapted to each tissue region and its various haemodynamic specificities. [3, 9, 11]
Arterioles pursue the smallest distal arterial branches and are usually connected to the distal meta-arterioles, which benefit from precapillary sphincters that coordinate and harmonise regional blood flow resistance to tissues. [10, 12]
A part of the proximal arterioles possesses, similarly to the macrocirculatory arteries, a thin smooth-muscle medial layer [10, 12] that participates directly in the coordination of the microcirculation and contributes to the development of MAS and MAC pathologies. [2, 12]
Capillary structure is centered around a basement membrane that harbours the endothelial cells, surrounded by pericyte cells. [2, 3, 10] All these essential histological constituents act as a selective natural barrier between the blood flow and the surrounding tissues. [9-12] This effective microcirculatory arrangement finally acts as a unique functional unit, playing a pivotal role in tissue perfusion, oxygen and nutrient diffusion, and in all parallel metabolic, hormonal, and immunological signalling. [10] It is governed by a central neural-mediated vasoactive counterbalance and by a local veno-arteriolar axonal reflex. [9, 12] This important and continuous interplay between macro- and microcirculation is known as haemodynamic coherence. [13]
Figure 2. A schematic representation of the arterial vasculature.
Commonly the arterial vasculature is divided into macro vs. microcirculation, upon the vessel’s diameter: “the macrocirculation” holds diameters > 100 μm), while the microcirculation refers to diameters < 100>
Abbreviations: DSA, digital subtraction angiography
Microcirculatory Pathological Pathways
Microcirculatory damage in the diabetic neuro-ischaemic foot syndrome is mainly generated by the noxious effects of chronic hyperglycaemia. [10-12] Persistent high glycaemic levels can induce both direct cellular toxicity at systemic level (including the widespread endothelial cells) and additional indirect ischaemic harm through the resulting hypoxia in all damaged microcirculatory endothelial organs and systemic regions [3, 12].
Hyperglycaemia essentially harms the mitochondria of the targeted cells, further inducing uncontrolled amounts of reactive oxygen species (ROS) with high tissue toxicity. [10, 11, 14] Concomitant deleterious metabolic
pathways, such as the hexosamine, polyol, and protein kinase pathways, further contribute to regional ROS accumulation. [3, 10-12]
In parallel, an accelerated glycation process generates excessive, irreversible advanced glycation end-products (AGEs), which activate macrophages and arteriolar smooth muscle cells, causing additional stress and injury to the vascular endothelium. [15] AGEs are also able to directly damage the endothelium of the arterioles and capillaries in the CLTI limb [11, 15] and to gradually impair the normal intravascular wall architecture by favouring intramural sclerosis, followed by hyalinosis, and finally by microcalcification deposits. [10, 11, 15]
These initial morphological changes (Figure. 3) are accompanied by early functional endothelial degeneration, leading to the loss of regional “haemodynamic coherence”. [13, 15] A precocious diagnosis and stratification of the initial endothelial cell damage are essential in the assessment and prognostic evaluation of the foot’s neuro-ischaemic mVD. [3, 11, 12, 15]
Ultimately, these intramural medial-layer transformations lead to local inflammation, increasing hydroxyapatite crystal deposition, irreversible medial layer destruction, and further extended calcifications (Figure. 3), ending in vessel loss. [4, 5]
Figure 3. Structural and functional damage in diabetic macro and microangiopathy.
A brief illustration of main structural and functional vascular impairment encountered in diabetic macro and microangiopathy in the context of medial artery sclerosis, calcification, an microvascular disease, independently from atherosclerotic affliction.
Abbreviations: BTA, below-the-ankle; BTK, below-the-knee
Interestingly, the same AGE cellular aggression equally enhances extravascular interstitial, muscular, and connective tissue fibrosis [10, 15] by damaging matrix proteins such as elastin, laminin, and type IV collagen.
In other words, mVD capillaries and arterioles must confront a dual mechanical adversity represented by: (i) intrinsic wall stiffening, and (ii) extrinsic perivascular conjunctive matrix “freezing”. These structural transformations induce functional alterations such as increased tissue hypoxia, local acidosis, inflammation, and loss of normal organ function. [12, 15]
Kintrup et al., in a nailfold capillaroscopy study of hypoxic limbs, [16] described severe rarefaction and distortions in capillary morphology that lead to uncontrolled microvascular vasomotor reactions and linked fluid extravasation with additional mVD wall thickening. [16] As a result, a decrease in normal blood flow parallel to increased microvascular resistance was also reported. [2, 9-11]
In a convergent study by Neubauer-Geryk et al. [17] it was observed that microvascular irregularities increase in parallel with the duration of diabetes and levels of haemoglobin A1c, and that specific endothelial cell injury and basement membrane thickening may vary in different organs with different anatomical and functional characteristics (e.g., differing processes described in the retina, peripheral nerves, myocardium, and musculoskeletal microvasculature). [10, 17]
Among the various systemic localisations of diabetic mVD, several organs have been extensively studied in the literature, [10] such as: the well-documented retinopathy and nephropathy, [11, 12] the microvascular heart damage (rest angina, myocardial stiffness, systolic-diastolic dysfunction, etc.), the lung microangiopathy (alveolar wall fibrosis, pulmonary hypertension, etc.), the brain microangiopathy (lacunar stroke, global cognitive decline and dementia), and the peripheral nerve hypoxic neuropathy (vasa nervorum depletion, parallel demyelination and axonal destruction, the neuropathic cutaneous “oxygen steal syndrome”, the loss of peripheral vasomotricity, and the concomitant “locking” of the microcirculation). [9, 18, 19]
Focusing on the macro- and microvascular peripheral disease in CLTI, this latter essentially involves the loss of the vasavasorum and synchronous capillary distortion and rarefaction in the affected foot. [17, 19] This complex process, only partially understood, leads to independent lower-limb arteriolar medial sclerosis with the formation of calcification hubs, and very likely contributes to the loss of microvascular wall autoregeneration. [3, 11, 19]
Notably, microangiopathic CLTI does not encompass only specific endothelial and medial layer microvascular changes but also additional constraints from a characteristic perivascular rigid, sclerotic, and further calcified environment, represented by concomitant musculoskeletal microangiopathy (diffuse fibrosis, limited joint and fascial mobility, ligamentous hypertension, and secondary neuro-ischaemic foot compartmental syndromes). [3, 10]
Interestingly, through reciprocal interaction, the presence of peripheral neuropathy appears correlated with a significant decrease in both the morphology and number of the foot’s nailfold capillaries (as a microangiopathic manifestation in diabetic neuropathic limbs). [3, 11, 17] Conversely, the progression of CLTI with advancing capillary hypoxia triggers inhibition of regional angiogenesis and vascular progenitor cell production; these hindrances in turn reinforce the local hypoxic, acidotic, and pro-coagulant milieu. [9-11, 19]
While part of the mVD clinical manifestations may be reversible (temporary regional loss of perfusion with compensation through “dormant” microvessels), [11, 19] other types of microvascular damage prove to be irreversible, as described by O’Neal et al. in their “end-artery occlusive disease” (EAOD) theory. [20]
Taking these circumstances into account, the role of wound- and flow-oriented foot reperfusion for better tissue healing has been amply discussed in the last decade’s literature [21] and seems to support the hypothesis of improved tissue recovery [21, 22] when applying, whenever technically feasible, the angiosome, EAOD, and woundosome theories. [21-23]
Applied clinical comments: Since macro- and microvascular damage in diabetic neuro-ischaemic CLTI limbs can express a myriad of clinical appearances, an intentional topographic revascularisation could be considered in these patients. This goal can be achieved by careful evaluation of the local vascular anatomy, the foot’s remaining patent arterial collaterals, the wound characteristics, and by taking into account the individual MAC, MAS, and mVD interrelated features as part of a unitary disease, according to each patient’s peri-operative risk class.
Clinical Aspects
In most of the cases, the diabetic neuro-ischaemic foot’s mVD develops silently (during months or years) until a notable clinical event (the passage from claudication to CLTI, extended foot wounds and sepsis, painful DPN, other hyperglycaemic systemic organ disorders, or sudden macrovascular atherosclerotic events) can disrupt the fragile perfusion balance created by regional arteriolar and capillary collateral compensation.
A parallel interplay (not fully understood) between CLTI, the severity of tibial and pedal arterial medial calcifications, and the presence of severe diabetic peripheral neuropathy (DPN) was already observed and emphasised since 1982 by Edmonds et al. [24] This concomitant microangiopathic interaction was recalled in contemporary CLTI and diabetic neuro-ischaemic foot literature, [25, 26] while its intimate molecular mechanisms still await to be decrypted. Nevertheless, below-the-knee (BTK) medial arterial calcifications in CLTI were found to represent an independent risk factor for MALE and major amputation, with or without manifest neuropathic affliction. [26, 27]
Stratification and related morbimortality
The diabetic neuro-ischaemic foot’s microangiopathy reunites arterioles and capillaries whose diameter varies between 100 μm and 5 μm (Fig. 2). Equally assimilated as mVD, [10-12, 18] this morbid entity does not at present benefit from a specific BTK or below-the-ankle (BTA) arteriolar and capillary consensual severity classification. [3, 9, 10, 12] The presence of “latent” foot microangiopathy [28] and the duration of diabetes [29] may represent independent severity factors for mVD, leading to higher morbidity and amputation [3, 9-12, 28].
Currently, MAS and MAC (apprehended as a unitary systemic pathology) comprise characteristic arterial tunica media lesions in vessels that naturally possess this layer (in other words, all the macro- and part of the microvascular arterial structures, excepting the vast capillary network) [3, 10-12]. This degenerative process is commonly encountered in patients with diabetes mellitus, renal insufficiency, and various chronic inflammatory systemic diseases; it is also coupled to ageing. [2-5] As stated hypothesis of this review, MAS and MAC may represent essential interrelated pathological components (probably expressing an evolutive link) [2-5] and may integrate a larger systemic macro- and mVD picture. [2-4] Several staging scores based on the MAC radiological morphology, extent, size, and distribution have been proposed in recent years to correlate and compare individual CLTI characteristics and prognostic outcomes [2, 4, 27, 28, 30-32].
Amputation risk in patients with CLTI exhibiting MAS and MAC
A conspicuous and updated analysis by Lanzer et al. [2] evaluated MAS and MAC as an independent, unitary systemic vascular pathological process, different from atherosclerosis, that comprises both sclerosis and calcification phenomenon at different evolving stages. Multiplane X-ray radiography allows differentiation between medial (“rail-tracking”) and intimal layer calcifications. [2, 4, 5] Thin-slice CT imaging and peripheral Duplex ultrasound studies may add information to support specific stratification in these patients. [2] The authors documented that the presence and the extent of MAC located in BTK arteries significantly associate with a major risk of developing CLTI, tissue and limb loss, together with high mortality rates [2]. Patients with MAC were also subject to low patency rates and higher revascularisation failure following interventions [4, 5].
Kim et al., in a 116-patient study exhibiting symptomatic PAD, [4] recently confirmed that high lower-limb MAC scores correspond with aggravating limb ischaemia; this correlation persisted even after adjustment for individual cardiovascular risk factors and the severity of occlusive disease. [4] In this study, MAC also appeared to directly correlate with higher rates of major amputation and mortality. [4]
A recently published prospective study involving 979 patients with diabetic foot ulcers, conducted over a nine-year period by Chen et al. [30] reported PAD in 53% and MAC in 8% of patients. Patients with PAD together with pedal MAC showed a significantly higher risk of amputation after adjusting for gender, age, albumin, haemoglobin, and diabetic retinopathy status. [30] Interestingly, although the presence of concomitant foot microangiopathy was not systematically evaluated, the presence of retinopathy was consistently recorded in the study protocol. [30]
An analogous paper by Liu et al. [31] examined a retrospective 250-patient cohort with CLTI over an eight-year period. The MAC score was applied for pedal artery evaluation using a minimum of two plain foot radiographic views. A higher score was significantly correlated with an increased risk of major amputation. [31]
In another distinct and convergent analysis dedicated to small artery disease (SAD) in association with MAC, a retrospective review was conducted on 223 patients with CLTI by Ferraresi et al. [32] The authors used a three-level imaging score based on angiographic findings for SAD and foot plain radiographs for MAC. They concluded that SAD and MAC represent manifestations of the same pathological process, in which the combined severity scores proved to be powerful predictors of amputation risk and MALE in patients with CLTI. It should be noted that this study is one of the few that associates radiographic MAC diagnosis with angiographic SAD (for the macrocirculation) and parallel TcPO₂ (for complementary microcirculatory assessment). [32]
Amputation risk in patients with CLTI adding specific foot’s mVD
Similar findings to those stipulating the deleterious MAC influence on limb preservation and mortality have been independently described with regard to the parallel presence of diabetic foot mVD. [3, 9, 11, 12] This represents a common, yet poorly diagnosed and monitored, dreadful diabetic complication. [3, 11, 12] It is known that among the microcirculatory structures, the vast capillary network does not exhibit an individualised medial layer capable of harbouring “potential” MAC deposits. [2-4, 11] Thus, focused microvascular assessment in CLTI, for studying these ubiquitous vessels (with <100>
A vast 125,000-patient diabetic cohort was followed longitudinally over a mean nine-year period by Behroozian et al., [12]. The authors assessed the reciprocal relationship between predominant microvascular diseases (retinopathy, neuropathy, and/or nephropathy) and peripheral limb microangiopathy, either in isolation or in association with PAD or CLTI [12]. Using Cox hazard regression, they demonstrated a 3.7-fold increase in amputation risk in the presence of lower-limb mVD alone. This risk expanded up to 22.7-fold with the additional presence of PAD or CLTI [12]. Interestingly, one in six major amputations occurred in the context of diabetic foot microangiopathy alone [12].
These observations were confirmed in a recent review by Biscetti et al., [33] who analogously found that the presence of diabetes in PAD and CLTI can increase the risk of major amputation tenfold through complex vascular interactions including systemic and local foot mVD [33].
Another recent and expressive mVD analysis was conducted by Jett et al. [34] in a 153-patient cohort with PAD. All patients underwent transcutaneous microcirculatory assessment by spatial frequency domain imaging (SFDI). [34] This technology combines structured illumination at multiple wavelengths in the visible and near-infrared light spectrum. The patients with PAD were divided into four groups of severity:
1.without diabetes,
2.with uncomplicated diabetes,
3.with diabetes + neuropathy,
4.with diabetes + neuropathy + retinopathy (severe systemic complications).
Following logistic regression analysis, the authors documented those patients with PAD associated with any form of mVD located at one or multiple sites exhibited a significant and progressive risk for wound development and for MALE evolution towards limb loss [34].
Our diabetic team’s research on the same topic developed an original four-grade (A–D) severity scale for the concomitant assessment of infra-malleolar macro/microvascular disease in CLTI feet [35]. In this retrospective study, the macrocirculatory angiographic features (pedal arteries, foot arches, and collaterals), combined with a dichotomic calcification evaluation, were complemented by parallel microcirculatory analysis using TcPO₂ and SPECT-scan imaging [35]. The results confirmed a significant difference in limb salvage rates observed in progressive severity from A to D grades, with the poorest outcomes recorded in grade D, which were distinctly analysed in patients with and without diabetes. [35]
All these observations concerning the significance of mVD for tissue and limb loss (parallel to its MAS and MAC interconnections) correspond with analogous results from contemporary CLTI publications. [3, 4, 9, 12, 27, 36] Notably, in patients with technically impossible or failed arterial revascularization, that associate severe mVD, MAS and MAC disease in the foot, the performance of inferior limb deep veins arterialisation could be considered as extreme indication for limb salvage. [3]
Applied clinical comments: MAC and MAS (analysed as interconnected entities), together with mVD (as a distinct pathology or accompanying both MAC and MAS), have a clearly significant and harmful influence on the diabetic foot, promoting tissue and limb loss. It also appears that mVD (vessels <100>
Diagnostic Techniques
Patients exhibiting mVD, MAS and MAC may initially lack ischemic signs and symptoms; this can be explained by the absence of hemodynamically severe arterial narrowing in early stages of disease. Due to the stiffness of peripheral arteries vessels, the ankle-brachial index (ABI) is often without clinical relevance. [2, 4, 11, 36-38]
MAC and MAS diagnostic methods currently gathers:
- Conventional radiography showing for MAC the classical “railroad track” images [4, 5].
- Computed Tomography, that can display MAC with 70% sensitivity [5].
- Pedal acceleration time [39] and arterial pulsatility index, [40] use extravascular ultrasound technology and can provide specific BTK ‘vascular resistance’ and ‘collateral reserve’ information [39, 40].
- Intravascular ultrasound (IVUS) can correctly describe MAS and MAC morphology; it remains however an invasive exam [4, 5].
- Extravascular ultrasound (EVUS) proves equally useful in MAS and MAC non-invasive exploration by direct wall analysis also by indirect pulsatility index assessment [38, 40].
- Optical coherence tomography offers high imaging resolution and affords a clear delineation of MAC and MAS, including the transition zone towards microcirculation and mVD [5].
Preferential mVD diagnostic (<100>
- Transcutaneous Pressure Oxygen monitoring (TcPO2) that measures the skin oxygen levels (using indirect capillary flow appraisal), [3, 12, 38]
- Near-Infrared Spectroscopy (NIRS) provides non-invasive, continuous tissue oxygen distribution data in specific foot regions [42].
- Laser Doppler flowmetry and skin perfusion pressure [41] adding Laser speckle [43] imaging display effective, non-invasive, and real-time analysis of territorial capillary flow in the foot [41, 43].
- Hyperspectral imaging can afford reliable monitoring of the foot microcirculatory oxygen saturation in deliberately targeted territories [44].
- Cutaneous video-capillaroscopy [16, 17] enables direct, high-resolution, morphological and functional capillary damage analysis
- Spatial Frequency Domain Imaging associates structural skin papillary haemoglobin evaluation, to functional tissue oxygen saturation data [34].
- Nuclear medicine: SPECT and PET scan technologies can provide direct intracellular, mitochondrial hypoxic tissue information [45]. Its diagnostic is not conditioned by the damaged flow in arterioles and capillaries in the CLTI foot. Available imaging can complete DSA information particularly for < 500>
- Novel Endovascular endothelial cell biopsy can be achieved by various techniques [47]. It displays with high accuracy a precocious diagnostic about the presence, the severity, and the prognostic of mVD endothelial damage in diabetic CLTI feet, owing 91% pooled technical success rate. [47] This modern technology can be associated to distal foot video-capillaroscopy and may add important information in distinguishing independent mVD either from upstream “macrovascular-induced” flow alteration, or from eventual parallel neuropathic cutaneous arteriolo-venular shunting [3, 12, 14, 19, 47].
Combined MAC and MAS information associating mVD diagnostic
- Indocyanine green angiography enables detailed anatomical and haemodynamic macro- and microcirculatory imaging of regional foot perfusion, facilitating eventual targeted revascularisation [48].
- Contrast-enhanced magnetic resonance is represented by arterial spin labelling (ASL) and blood oxygenation level-dependent (BOLD) techniques; it allows a direct study of microvascular flow in capillaries associated with an indirect appraisal of tissue oxygen saturation [49].
Applied clinical comments: The diabetic neuro-ischaemic foot’s microangiopathy may also exhibit various insidious clinical forms, particularly in patients with chronic, multifactorial, hypoxic foot ulcers. These patients may have palpable peripheral pulses and apparently acceptable macrocirculatory Duplex waveforms in BTK arteries, and are not necessarily suspected of being at high risk of limb loss. Careful systemic double-checking in search of other parallel systemic microangiopathic locations, together with at least two consecutive microcirculatory foot examinations (TcPO₂, NIRS, laser flowmetry, skin capillaroscopy etc.,), may help the experienced clinician to unveil these atypical CLTI forms presenting predominantly as mVD.
Treatment Options
Macrovascular revascularisation (by open surgery or endovascular techniques) in patients exhibiting PAD and CLTI remains the gold standard in current practice. However, this paradigm cannot constantly predict accurate target tissue regeneration, [37, 38] particularly in diabetic neuro-ischaemic limbs, [4, 5] which may present poor collateral reserve and an exhausted macro- and microvascular foot run-off. [4, 12, 20, 38]
From a contemporary perspective, MAC, MAS, and mVD can be perceived as stages of the same degenerative systemic vascular disease, observed at different unfolding grades, vascular wall architectures, and timelines. [3] This process may act independently and in parallel with atherosclerotic damage and its specific risk factors. [3, 10, 12, 32]
At present, there is no consensual therapy specifically dedicated to diabetic MAC and microangiopathy. [3, 5]
Several studies have evaluated a hypothetical benefit from using monitored aerobic exercise, phosphodiesterase-3 inhibitors (with vasodilatory effects), [15] additional vitamin K preparations, [5, 50] specific betaine supplementation in the diet (expecting reduction of “oxygen reactive species”), [3, 11] acetazolamide and aldosterone periodic treatment, [5, 19] etc. The clinical results have remained disappointing.
Applied clinical comments: The CLTI diabetic foot requires prompt macro- and microvascular diagnostic evaluation followed by expeditious macrovascular revascularisation and best multidisciplinary diabetic team treatment. Although accessibility in daily practice may vary, microcirculatory diagnostic assessment should form part of any CLTI evaluation. Systematic surveillance through a regular diabetic foot multidisciplinary team appears mandatory.
- One major limitation of this review is represented by the difficulty of drawing synthetic information from the vast “diabetic microangiopathy” field, which is far from being conspicuously acknowledged. Other technical impediments are mentioned in the literature and concern:
- A precise distinction between medial and intimal calcifications in small arterial branches, [4] particularly at the arteriolar microcirculatory junction, using plain X-rays and current CT imaging, appears challenging for some practitioners. [4]
- Unlike the cardiological assessment, regarding peripheral MAC, various methodological protocols are currently in use, which may contribute to a less uniform qualitative and quantitative calcific appraisal. [4, 19]
Perspectives
Recent research has shown that genes associated with type 2 diabetes are also linked to retinopathy and neuropathy involvement [51] as microvascular-related pathologies, requiring further clinical investigation. [51]
Parallel research shows that the anti-aging gene Sirtuin 1 is critical to the prevention of diabetes, cardiovascular disease, ischemia and systemic inflammation. [52] The role of Sirtuin 1 activators vs. inhibitors is critical to the treatment and prevention of diabetic microangiopathy. The early activation of Sirtuin 1 may improve microangiopathic disease in diabetic neuro-ischaemic feet with relevance to tissue and limb loss. [52] The systematic mVD screening at systemic, and at the foot level appears as essential strategy, reiterated by the recent American Diabetes Association on retinopathy, neuropathy, and foot standards of care in Diabetes-2026. [53]
A high calcific MAC score appears significantly associated with increased major adverse limb events, amputation risk, and mortality in patients with PAD and CLTI. The presence of microangiopathic disease in diabetic neuro-ischaemic feet has likewise proven a deleterious influence on tissue and limb loss, which worsens when parallel systemic localisations are present. Diabetic microvascular disease seems correlated with the medial arterial sclerosis and calcification processes, as interrelated stages of a systemic, macro- and microcirculatory, non-atherosclerotic pathology, carrying an independent and adverse prognostic significance for limb loss.
The corresponding author acknowledges Professor Vincent Tchana-Sato, for his courtly support in refining this paper.
Conceptualization and design: VA and AK; research and data curation: VA; methodology of presentation: VA and KD; administrative tasks: VA; visualization and chapter integration: VA, and KD; writing, editing and critically reviewing: all author’s contribution; supervision: VA; validation: by all authors. All authors read and approved the final manuscript.
Not applicable.
This research received no external funding.
The authors declare no conflict of interest.
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Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
