Mönckeberg's medial calcific sclerosis in diabetic and non-diabetic foot infections.

The aim of this study was to evaluate the prevalence and extent of lower extremity Mönckeberg's Medial Calcific Sclerosis (MMCS) in patients with and without diabetes in patients admitted to the hospital for foot infections. This study retrospectively reviewed 446 patients admitted to the hospital with a moderate or severe foot infection. We defined diabetes based on ADA criteria and reviewed electronic medical records for demographics, medical history and physical examination data. Anterior-posterior and lateral foot radiographs were examined to identify the presence and extent of vascular calcification. We categorised MMCS based on anatomical location: ankle joint to the navicular-cuneiform joint, Lis Franc joint to metatarsophalangeal joints and distal to the metatarsophalangeal joints. The prevalence of MMCS was 40.6%. The anatomic extent of MMCS was 19.3% in the toes, 34.3% in the metatarsals and 40.6% in the hindfoot/ankle. Calcification was not common solely in the dorsalis pedis artery (DP) (3.8%) or solely in the posterior tibial artery (PT) (7.0%). Usually, both DP and PT arteries were affected by MMCS (29.8%). The prevalence of MMCS was higher in people with diabetes (in hindfoot and ankle [50.1% vs. 9.9%, p ≤ 0.01]; metatarsals [42.6% vs. 5.9%, p ≤ 0.01]; and toes [23.8% vs. 4.0%, p ≤ 0.01]). People with diabetes were 8.9 (CI: 4.5-17.8) times more likely to have MMCS than those without diabetes. This is a group that often has poor perfusion and needs vascular assessment. The high prevalence of MMCS raises questions about the reliability of the conventional segmental arterial Doppler studies to diagnose PAD.

Mönckeberg's Disease of the Lower Limb.

Vascular calcification represents a group of several pathological states of differing aetiologies. Mönckeberg medial sclerosis is considered to be more widespread in the lower abdominal region and lower limbs. We present a 59-years-old male patient presented right foot gangrene. At physical exploration, femoral and popliteal pulses were presented and the ankle-brachial pressure index was 0.45, and the toe-brachial index was 0.33. The patient underwent distal angioplasty of anterior and posterior tibial arteries and due to inaccurate evolution a transmetatarsal amputation was required. Mönckeberg's medial sclerosis is diagnosed with an ABI>1.1, however, questions have been raised about the validity and the role of ABI in diagnosis of Mönckeberg's medial sclerosis. Colour-doppler vascular ultrasound allow a non-invasive technique widely available to detect vascular calcification and to differentiation between Mönckeberg's medial sclerosis and the atherosclerosis-related lesions.

Arterioesclerosis de Monckeberg en vasos uterinos: un interesante hallazgo incidental / Arteriosclerose de Monckeberg nos vasos uterinos: um achado incidental interessante / Monckeberg arteriosclerosis in uterine vessels: an interesting incidental finding

Se realizó la comunicación de un caso clínico-patológico, diagnosticado en el Hospital Docente Clínico Quirúrgico "Joaquín Albarrán" de La Habana. En dicha entidad se presentó en una paciente femenina de 85 años de edad con antecedentes de diabetes mellitus tipo 2, ingresada por cuadro de insuficiencia arterial de miembro inferior izquierdo por lo cual se le realizan amputación supracondilia y al tercer día de su estadía hospitalaria, fallece. En la autopsia se arribó al diagnóstico anatomopatológico de arterioesclerosis de Mönckeberg de vasos del útero. Esta es una forma de arterioesclerosis muy relacionada con la senectud, pero factores de riesgo como diabetes mellitus y la enfermedad renal crónica pueden contribuir de forma directa en su desarrollo y progresión. Su diagnóstico es un hallazgo incidental en muestras histopatológicas(AU)

A clinical-pathological case was reported, diagnosed at the Joaquín Albarrán Clinical Surgical Teaching Hospital in Havana. In this entity, an 85-year-old female patient with a history of type 2 diabetes mellitus was presented, admitted due to arterial insufficiency of the lower left limb, for which she underwent supracondylar amputation and died on the third day of her hospital stay. At the autopsy, the pathological diagnosis of Mönckeberg arteriosclerosis of vessels of the uterus was reached. This is a form of arteriosclerosis closely related to old age, but risk factors such as diabetes mellitus and chronic kidney disease can directly contribute to its development and progression. Its diagnosis is an incidental finding in histopathological samples(AU)

Um caso clínico-patológico foi relatado, diagnosticado no Hospital de Clínica Cirúrgica "Joaquín Albarrán" em Havana. Nessa entidade, apresentou-se uma paciente de 85 anos, com história de diabetes mellitus tipo 2, internada por insuficiência arterial do membro inferior esquerdo, para a qual sofreu amputação aupracondiliana e faleceu no terceiro dia de internação. Na autopsia, o diagnóstico patológico da arteriosclerose de Mönckeberg de navios do útero foi conseguido. Essa é uma forma de arteriosclerose intimamente relacionada à velhice, mas fatores de risco como diabetes mellitus e doença renal crônica podem contribuir diretamente para seu desenvolvimento e progressão. Seu diagnóstico é um achado incidental em amostras histopatológicas(AU)

Imaging Features of Soft-Tissue Calcifications and Related Diseases: A Systematic Approach.

Soft-tissue calcification refers to a broad category of lesions. Calcifications are frequently identified by radiologists in daily practice. Using a simple algorithm based on the distribution pattern of the lesions and detailed clinical information, these calcified lesions can be systematically evaluated. The distribution pattern of the calcific deposits enables initial division into calcinosis circumscripta and calcinosis universalis. Using laboratory test results (serum calcium and phosphate levels) and clinical history, calcinosis circumscripta can be further categorized into four subtypes: dystrophic, iatrogenic, metastatic, and idiopathic calcification. This pictorial essay presents a systematic approach to the imaging features of soft-tissue calcifications and related diseases.

[АRTERIAL PRESSURE ON THE FIRST TOE AS A PROGNOSIS CRITERION OF THE COMPLICATION OCCURRENCE IN THE DIABETIC FOOT SYNDROME ON BACKGROUND OF MENKEBERG'S SCLEROSIS].

In the patients, suffering diabetes mellitus type ІІ, treated in 2015 - 2016 yrs for complicated diabetic foot syndrome, a systolic arterial pressure (SAP) on level of the first toe was determined, and roentgenography of the foot in two projections done. The SAP value from 120 to 200 mm Hg and higher have had witness the presence of Menkeberg?s sclerosis stages III - V. Prognostically favorable is a SAP value of 80 mm Hg and higher, and unfavorable data ­ the SAP value lowering lesser than 80 mm Hg. The SAP value lower than 30 mm Hg have had witness the vessel obliteration and thrombosis occurrence.

[When the tissue tolerance fiber tears]. / Wenn der Gewebegeduldsfaden reisst .

We report a 65 year old patient who presented with both an aneurysm of the axillary artery and, some years later, with an acute aortic dissection type Stanford A. After surgical intervention of the dissection in the further workup, no specific etiology could be found. The most likely reason for the two aneurysms was the inadequately treated hypertension. Therefore, follow-up strategies aim to treat the risk factors which are known to promote aneurysm growth.

Upper limb vascular calcification score as a predictor of mortality in diabetic hemodialysis patients.

OBJECTIVE: This study evaluated the correlation between an upper limb vascular calcification (Vc) score (VcS) and late all-cause mortality in diabetic hemodialysis patients with distal upper limb arteries medial wall sclerosis (Mönckeberg disease). METHODS: We retrospectively reviewed Vc in bilateral upper limb plain radiographs and in duplex ultrasound images performed before radial-cephalic fistula (RCF) creation in diabetic hemodialysis patients. Only medial linear calcifications outlining the vessel wall were considered positive on X-ray images, whereas for ultrasound reviews, only continuous highly echogenic plaques producing bright white echos with shadowing were considered to be medial calcification. A VcS was then applied in each patient. Every half of each of the three main arterial conduits (brachial, radial, and ulnar arteries) in each arm was counted as 1 if it contained ≥ 6 cm of linear calcification, whereas absence of calcification or minimum calcification (length <6 cm) was counted as 0. Long-term all-cause mortality was compared between patients with a low or moderate VcS <8 (group I), patients with a high VcS ≥ 8 (group II), and patients with VcS = 0 (control group). Kaplan-Meier statistics were used for comparisons among the groups. RESULTS: Nineteen patients had a VcS <8, 21 had VcS ≥ 8, and 43 patients had VcS = 0. The study patients had a mean age of 68 ± 10 years (range, 42-83 years; P = .23). Before early conversion to a RCF, dialysis therapy in 59 (71.1%) had already been initiated through central venous catheters (CVCs). The mean follow-up for groups I, II, and controls was 41.4 ± 41.2 months (range, 4-144 months), 34.15 ± 31.3 months (range, 1-108 months), and 66.7 ± 32.5 months (range, 12-126 months), respectively (P = .0009). Forty-seven patients died during the follow-up period (12 in group II and 24 in the controls; P = .88). Survival rates at 12, 24, 36, and 48 months were 78.3%, 65.7%, 54.8%, and 48.1% for group I; 75.2%, 58.8%, 49.3%, and 42% for group II; and 97.7%, 93.1%, 76.8%, and 71.8% for the control group, respectively (P = .013 for all groups; P = .044 for group II vs controls). Patients with (subgroups) or without CVCs at baseline had similar late mortality rates. Patients with CVCs/Vc had lower survival rates than those with CVCs/no Vc at 1 year (73.3% vs 96.5%) and at 3 years (47.7% vs 75.8%; P = .038). CVCs were related to increased risk of death only in subgroup II patients compared with the subcontrol group patients (75.4% vs 37.9% at 5 years, respectively; P = .034). CONCLUSIONS: Diabetic hemodialysis patients exposed to high levels of upper extremity arterial medial VcSs upon receiving RCFs have an increased long-term mortality risk compared with diabetic hemodialysis patients with no Vc and receiving the same access. Patients with CVCs/Vc had the lowest survival rates.

Mönckeberg's arteriosclerosis: vascular calcification complicating microvascular surgery.

Mönckeberg's arteriosclerosis is often an incidental finding, identified either clinically or on plain radiography. It can occasionally be associated with diabetes mellitus or chronic kidney disease. It differs from the more common atherosclerosis in that the tunica intima remains largely unaffected and the diameter of the vessel lumen is preserved. Despite such vessels appearing hard and pulseless throughout their affected length, they deliver relatively normal distal perfusion, indeed there is often a bounding pulse at the end of the calcified zone. They appear unremarkable on magnetic resonance angiography but visibly calcified on plain radiography. Mönckeberg's arteriosclerosis has a prevalence of < 1% of the population, but when it does occur it can cause consternation at the prospect of using these vessels for microvascular anastamosis. We report our experience of deliberately using these vessels in an osseocutaneous radial forearm free flap reconstruction. Although there are some technical considerations to bear in mind, we would suggest that unlike vessels affected by atherosclerosis, anastomosis of arteries affected by Mönckeberg's arteriosclerosis has little or no impact on free flap survival.

Management of microanastomosis in patients affected by vessel diseases.

OBJECTIVE: In the last 10 years with the advances in microsurgery of techniques and materials the indications for free tissue transfer have considerably been increased. But, there are still some limitations and drawbacks. Among risk factors associated with flap failure, atherosclerosis can affect both the flap and the recipient vessels of free microvascular tissue transfers. The purpose of this paper is to discuss about the pathogenesis of Monckeberg's sclerosis, and the topics that must be taken into consideration when performing microsurgery in these patients. METHODS: PubMed database was searched using Mesh. The following terms was added to the search builder: Monckeberg's sclerosis, free flap. The Boolean operator "AND" was selected. All the selectable Mesh headings for "Monckeberg's sclerosis" and "free flap" were included. RESULTS: Almost all the literature works about microsurgery in Monckeberg's sclerosis patient show the importance of an accurate preoperative and postoperative evaluation and of a proper surgical technique. CONCLUSIONS: When adequate preoperative evaluation, surgical technique and postoperative monitoring are performed, even severe atherosclerosis should not be considered an absolute contraindication for microvascular surgery.

Peripheral arterial calcification: prevalence, mechanism, detection, and clinical implications.

Vascular calcification (VC), particularly medial (Mönckeberg's medial sclerosis) arterial calcification, is common in patients with diabetes mellitus and chronic kidney disease and is associated with increased cardiovascular morbidity and mortality. Although, the underlying pathophysiological mechanisms and genetic pathways of VC are not fully known, hypocalcemia, hyperphosphatemia, and the suppression of parathyroid hormone activity are central to the development of vessel mineralization and, consequently, bone demineralization. In addition to preventive measures, such as the modification of atherosclerotic cardiovascular risk factors, current treatment strategies include the use of calcium-free phosphate binders, vitamin D analogs, and calcium mimetics that have shown promising results, albeit in small patient cohorts. The impact of intimal and medial VC on the safety and effectiveness of endovascular devices to treat symptomatic peripheral arterial disease (PAD) remains poorly defined. The absence of a generally accepted, validated vascular calcium grading scale hampers clinical progress in assessing the safety and utility of various endovascular devices (e.g., atherectomy) in treating calcified vessels. Accordingly, we propose the peripheral arterial calcium scoring system (PACSS) and a method for its clinical validation. A better understanding of the pathogenesis of vascular calcification and the development of optimal medical and endovascular treatment strategies are crucial as the population ages and presents with more chronic comorbidities.

[Medial calcific sclerosis under long-term anticoagulation with vitamin K antagonists]. / Mediasklerose als Folge der Langzeitantikoagulation mit Vitamin-K-Antagonisten.

BACKGROUND: Vitamin K antagonists not only influence the synthesis of coagulation factors but also the activation of other vitamin K dependent proteins. Among other possible side effects, arterial calcification has been focused on in recent years. HISTORY AND FINDINGS: Four patients under long-term anticoagulation for more than 10 years developed medial calcific sclerosis. In case 1 we identified an unexplained medial calcific sclerosis on x-ray after a trauma by chance. After that we examined the ankle-brachial index of blood pressure in all patients who had received long-term anticoagulation for more than 10 years. Where the index exceeded 1,3 we performed a x-ray-examination of the forefoot. Of the four described patients no one suffered from diabetes mellitus, renal failure or hyperparathyreoidism. Serum calcium was normal in all patients. The severity of the medial calcific sclerosis could not be explained by the initial vascular risk factors. CONCLUSION: In certain patients, even at low vascular risk, a medial calcific sclerosis can appear under long-term anticoagulation with vitamin K antagonists. We conclude that vitamin K antagonists inhibit several proteins which protect the vessels from calcification leading to medial calcific sclerosis.

Impact of atherosclerotic risk factors on different ankle-brachial-index criteria--results of the Heinz Nixdorf RECALL study.

BACKGROUND: On the basis of the Heinz Nixdorf RECALL Study (HNR) we estimated the impact of classical atherosclerotic risk factors on different ankle-brachial-index (ABI) criteria. PATIENTS AND METHODS: In a subgroup of participants (n = 2586) who had normal ABI at baseline ABI measurement was repeated at a 5 years follow-up and 3 different ABIs were defined: "ABI-high" calculated from the higher pressure, "ABI-low" from the lower pressure of both foot arteries of each leg. "Pure-ABI-low" was defined by exclusion of participants with ABI-high from those with ABI-low. Mönckebergs mediacalcinosis (MC) was accepted in case of ABI-high > 1.4 in one leg. RESULTS: According to ABI-high 2 %, to ABI-low 7.8 % and pure-ABI-low 5.8 % of the participants developed peripheral arterial disease (PAD) (ABI < 0.9) and 3.6 % developed MC within the 5 years. Age did not play any role whereas female gender, diabetes mellitus and smoking were associated with an increased relative risk of pathologic ABI-high and ABI-low. Looking at the pure-ABI-low group only, female gender and smoking showed significant associations. None of the analysed risk factors except gender had an impact on the development of MC. CONCLUSIONS: Classical risk factors have different impact on incidence of PAD as defined by different ABI criteria.

Clinical detection, risk factors, and cardiovascular consequences of medial arterial calcification: a pattern of vascular injury associated with aberrant mineral metabolism.

Patients with end-stage renal disease are characterized by extensive vascular calcification and high cardiovascular disease (CVD) risk. Calcification in end-stage renal disease patients represents at least two distinct pathologic processes. Calcification within the tunica intima frequently is associated with lipid-laden, flow-limiting atherosclerotic plaques. These appear as spotty areas of calcification interspersed with noncalcified arterial segments on plain radiography and generally are found near arterial branch points in medium-sized conduit arteries. In contrast, medial arterial calcification (MAC) involves deeper layers of the arterial wall; tends to affect the artery diffusely, appearing as a linear contiguous tram-track pattern of calcification on plain radiography; and often involves smaller muscular arteries such as the radial artery, intermammary arteries, and arteries in the ankle and foot. Both are related to CVD events, but potentially through different mechanisms. Atherosclerotic calcification may be marking the total burden of atherosclerosis, whereas MAC may lead to arterial stiffness and left ventricular hypertrophy. Existing data suggest that altered mineral metabolism may promote MAC, whereas heightened inflammation and oxidative stress contribute to atherosclerosis. Dysregulation of normal anticalcification factors and elastin degradation are common to both processes. Risk of vascular calcification also may be increased by the use of certain medications in the setting of chronic kidney disease. This review compares and contrasts known risk factors for MAC and atherosclerosis, describes existing and emerging technologies to distinguish between them, and reviews the existing literature linking each with CVD events in dialysis patients and in other settings.

Incidentally detected Monckeberg's sclerosis in a diabetic with coronary artery disease.

We report the case of a 62-year-old diabetic man, who was incidentally detected to have extensive calcification in his upper limb arteries, consistent with Monckeberg's sclerosis. The condition was identified when routine radial puncture attempted in the course of coronary angiography was repeatedly unsuccessful. Coronary angiography and angioplasty was subsequently performed through the femoral route. Monckeberg's sclerosis is a poorly understood condition associated with generalised atherosclerosis and chronic kidney disease. The pathogenesis and natural history of Monckeberg's sclerosis are briefly discussed.