Mönckeberg Medial Arteriosclerosis in a Geriatric Patient with Chronic Kidney Disease and Poorly Controlled Diabetes Reporting for a Dental Recall Visit.

Mönckeberg medial arteriosclerosis is a condition characterized by the calcification of the tunica media layer of the blood vessels that are visible on plain radiography or sectional tomography. In dentistry, a properly acquired panoramic radiograph may show the condition incidentally. It is also known as medial arterial calcinosis and can be associated with diabetes mellitus or chronic kidney disease. This condition is different from the more common atherosclerosis where the tunica intima remains unaffected, and the diameter of the vessel lumen is preserved. Dental treatment can be performed when the patient is stable with medically controlled diabetes.

Mönckeberg's medial arteriosclerosis in the oral and maxillofacial region: A pilot study.

OBJECTIVE: To evaluate the prevalence of medial vascular calcifications in the oral and maxillofacial region and their association with systemic diseases. MATERIALS AND METHODS: The study included 211 consecutive patients with systemic diseases (January 2015-May 2016). Medical history and radiographic images were evaluated. Univariate analysis (t-test) was performed for continuous variables (age). The Chi square test was applied for the categorical variables (Mönckeberg medial arteriosclerosis [MMA], gender). RESULTS: There was a 6.2% prevalence of MMA. The mean age of patients with MMA was 65.46 ± 13.38. The prevalence of kidney disease in patients with MMA was significantly higher than in those without MMA (p < 0.001). This finding was maintained even after adjusting for other systemic diseases (OR = 31.84 [8.63-136.78]). CONCLUSION: A significant prevalence of MMA in kidney disease patients was observed in this pilot study.

Monckeberg's Medial Sclerosis as a Cause for Headache and Facial Pain.

PURPOSE OF REVIEW: Mönckeberg's medial sclerosis (MMS) is a chronic, non-inflammatory degenerative condition affecting primarily the tunica media of muscular arteries resulting in their calcification. The purpose of this comprehensive review is to describe MMS as it appears in the literature, in the context of headache and facial pain. Understanding the etiopathology, the associated conditions, and the differential diagnoses is important in managing MMS. RECENT FINDINGS: Management of MMS primarily depends upon identification of its associated conditions and their treatment. Due to the rare incidence and inadequate literature on MMS presenting with headaches, the diagnosis of the pain and the entity itself is challenging. MMS is characterized by associated systemic conditions and absence of inflammatory markers. It can mimic giant cell arteritis (GCA) and other pain entities. An interdisciplinary approach involving appropriate specialties is recommended.

The impact of pre-existing radial artery pathology by histological assessment on the maturation, function and patency of the radiocephalic fistula for hemodialysis.

BACKGROUND: We prospectively analyzed the effect of preexisting structural changes of the radial artery (RA) wall by histological examination on the wrist radiocephalic fistula (RCF) outcomes. METHODS: During RCF creation, one segment of the RA wall was collected and its histomorphometric analysis was performed. The RCF function was evaluated by measuring blood flow rate. RESULTS: At the end of follow-up, 75.7% of the thirty-seven patients enrolled were performing hemodialysis by using their successful RCF and 24.3% of them showed early RCF failure. Compared to patients with a healthy RA, the RCF of those with medial RA microcalcification reached up a lower flow and a shorter primary patency (P=0.005 and P=0.040, respectively). The RA microcalcification was predictive of the RCF function (coefficient -614.9, 95% CI: -994.7 to -235.1, P=0.003). Compared to patients with successful RCF, those with failed RCF had a greater frequency of weak RCF thrill after releasing the clamps (P=0.045). Dependence on hemodialysis during RCF placement was predictive of its early failure (OR: 23.2, 95% CI: 1.76 to 306.9, P=0.017). Both having at least one cardiovascular comorbidity (HR 4.30, 95% CI: 1.29 to 14.39, P=0.018) and a thicker media layer of the RA (HR 1.60, 95% CI: 1.87 to 2.15, P=0.002) were predictive of primary RCF patency. CONCLUSIONS: The function and survival of the successful RCF were related to preoperative RA abnormalities such as microcalcification and media layer thickness. Both dependence on hemodialysis during RCF placement and an attenuated RCF thrill were associated with early RCF failure.

Media sclerosis drives and localizes atherosclerosis in peripheral arteries.

Media sclerosis (MS) and peripheral artery disease (PAD) may coincide, particularly in type 2 diabetics (T2D) and in patients with chronic kidney disease (CKD). In contrast to non-diabetics, in T2D PAD is more severe and more distal. Although MS is suspected to play a role, the underlying pathophysiological reasons for the differences still remain elusive today. We tested the hypothesis that MS is a promoter of atherosclerosis as it occurs in T2D with PAD by interfering with arterial remodeling using an in-silico simulation. We confirmed that MS aggravates PAD by promoting negative remodeling. We found that the effect is more pronounced in smaller distal arteries compared to larger proximal ones. Our results suggest that the degree of this divergence depends on the ratio between the thickness of the intima relative to the thickness of the media/adventitia of the individually affected arteries.

[EFFICACY OF CYTOFLAVIN IN COMPLEX TREATMENT OF DIABETIC FOOT SYNDROME].

The study involved 97 patients with severe diabetic foot syndrome (DFS) subcompensated type 2 diabetes. All patients were available mediacalcification foot and lower leg arteries of different severity. Depending on the treatment, all patients were divided into 2 groups by stratified randomization. The І group received standard therapy, which is indicated for the DFS. A ІІ group of patients additionally received basic therapy drug Cytoflavin 10 ml 0,9% NaCl 200 ml for 10 days, followed by transfer to tablet form Cytoflavin 2 tablets 2 times per day orally for one month. We noted a positive trend of treatment of patients who, in addition to standard therapy received the drug Cytoflavin. Thus, the use of complex surgical treatment of patients with mixed form of DFS Cytoflavin reduces the severity of distal polyneuropathy, improves oxygenation of tissues and restores the enzyme activity of antioxidant system, that manifested neuroprotective, antioxidant and anti-hypoxic effects of drugs, which substantiates the indications for its use in the this pathology.

18F-sodium fluoride PET/CT for the in vivo visualization of Mönckeberg's sclerosis in a diabetic patient / PET/TC con 18F-fluoruro sódico en la visualización in vivo de la esclerosis de Mönckeberg en un paciente diabético

Diabetes is a major frequent cause of atherosclerosis vascular disease. Arterial calcification in diabetic patients is responsible for peripheral vascular involvement. Molecular imaging using 18F-sodium fluoride (18F-NaF) positron emission tomography (PET)/computed tomography (CT) has been recently proposed as a marker to study the in vivo mineralization process in the atheroma plaque. A 69-year-old man with a history of type 2 diabetes and no clinical evidence of peripheral arterial disease underwent an 18F-NaF PET/CT scan. A linear, well-defined 18F-NaF uptake was detected along the femoral arteries. In addition, the CT component of the PET/CT identified an unsuspected “tram-track” calcification in his femoral arteries, suggestive of medial calcification (Mönckeberg's sclerosis). In other vascular territories, focal 18F-NaF uptake was also detected in carotid and aorta atheroma plaques. Molecular imaging with 18F-NaF PET/CT might provide new functional information about the in vivo vascular calcification process in diabetic patients (AU)

La diabetes es una causa frecuente de enfermedad vascular aterosclerótica. La calcificación vascular en pacientes diabéticos es responsable de la afectación vascular periférica. Recientemente se ha propuesto la imagen molecular usando tomografía por emisión de positrones (PET)/tomografía computerizada (TC) con 18F-fluoruro sódico (18F-NaF) como marcador para estudiar “in vivo” el proceso de mineralización en la placa de ateroma. Presentamos los hallazgos de la PET/TC 18F-NaF en un varón de 69 años con historia de diabetes tipo 2 y sin evidencia clínica de enfermedad arterial periférica. La PET/TC 18F-NaF demostró una captación lineal, bien definida, a lo largo de las arterias femorales. Además la componente TC de la PET/TC identificó un patrón de calcificación “en vías de tranvía” (“tram-track” pattern) en las arterias femorales sugestivo de calcificación de la capa media arterial (esclerosis de Mönckeberg). En otros territorios vasculares se detectó captación focal de 18F-NaF en placas de ateroma carotídeas y aórticas. La imagen molecular con PET/TC 18F-NaF podría proporcionar nueva información funcional sobre el proceso de calcificación vascular “in vivo” en pacientes diabéticos (AU)

[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.

A case of successful percutaneous transluminal septal myocardial ablation for heart failure due to severe left ventricular outflow obstruction with Mönckeberg's arteriosclerosis, manifested after aortic valvular replacement.

Although percutaneous transluminal septal myocardial ablation (PTSMA) has been the established treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), the efficacy for specific HOCM is not elucidated. We report a successful case of PTSMA for heart failure with severe left ventricular outflow tract (LVOT) obstruction due to sigmoid-shaped interventricular septum and diffuse left ventricular hypertrophy with Mönckeberg's arteriosclerosis and aortic valvular stenosis. While the PTSMA relieved LVOT obstruction and symptoms in the acute phase, the modest recurrence was confirmed 6 months later, which is rare in the case of idiopathic HOCM. The possible mechanisms of LVOT obstruction and recurrence are discussed.

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.

Correlation of pre-existing radial artery macrocalcifications with late patency of primary radiocephalic fistulas in diabetic hemodialysis patients.

OBJECTIVE: The aim of this study was to evaluate the impact of pre-existing radial artery macrocalcification (Mönckeberg type of arteriosclerosis) on patency rates of radiocephalic fistulas (RCFs) in diabetic end-stage renal disease (ESRD) patients undergoing hemodialysis. METHODS: In this observational prospective study, the long-term patency rates (primary outcome measures) of RCFs in ESRD diabetics who had Mönckeberg radial (±brachial) artery disease (calcified [C] group) were compared with those obtained in ESRD diabetics who had healthy, noncalcified vessels before RCF construction (healthy [H] group). Vessel calcification was assessed by plain two-dimensional radiography. For inclusion in the C-group, uniform linear railroad track-type macrocalcifications of at least 6 cm in length, in the medial wall of the radial artery ipsilateral to RCF creation, were required. Patients were included in the H-group if the radial artery ipsilateral to the RCF creation was free of any macrocalcification, of either intima or media type. Any intimal-like plaque with irregular and patchy distribution was an exclusion criterion for both groups. Patients in both groups also were required to have suitable upper limb vascular anatomy on the basis of ultrasound imaging before RCF creation (cephalic vein of minimum diameter of 1.6 mm, without stenosis or thrombosis in all outflow areas, and radial artery of minimum diameter of 1.5 mm, without proximal hemodynamically significant stenosis). Secondary outcome measures included all-cause mortality. Kaplan-Meier statistics were used for comparison between groups. RESULTS: The arm radiograph at the site of possible fistula construction showed abnormality in 39 patients (C-group, 47 RCFs), whereas 33 patients had noncalcified ("healthy") vascular anatomy (H-group, 40 RCFs). Mean duration of the diabetic disease at the time of RCF creation was 8.9 ± 5.6 years (range, 2-25 years) for the H-group and 14 ± 9.9 years (range, 1-40 years) for the C-group (P = .018). The mean follow-up period for H-group and C-group was 51.9 ± 35.9 months (range, 0.1-126 months) and 26.1 ± 31.6 months (range, 0.1-144 months), respectively (P = .0006). Forty-four patients died during the follow-up period. Primary patency rates at 12, 24, 36, and 48 months for C-group vs H-group were 50.2% vs 80%, 36.5% vs 72.3%, 32.4% vs 67.9%, and 29.1% vs 59.3% (P = .0019). Respective values for secondary patency rates were 52.4% vs 87.5%, 40.9% vs 82.4%, 36.6% vs 78.1%, and 33.2% vs 72.8% (P = .00064). Patient survival rates at 24 and 48 months were 56.1% and 46.4% for C-group and 92.4% and 67.4% for H-group, respectively (P = .05). CONCLUSIONS: ESRD diabetics with radial artery Mönckeberg calcifications receiving RCFs had worse late clinical outcomes compared with ESRD diabetics with healthy distal arm vessels receiving the same access. The long-term benefit of RCFs may be lost in diabetics with extensively calcified vessels, and preferably the brachial artery should be used instead.

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.