YIJOM-3019; No of Pages 3

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2014.10.011, available online at http://www.sciencedirect.com

Case Report
Reconstructive Surgery

Mönckeberg’s arteriosclerosis: B. Castling1, S. Bhatia1, F. Ahsan2

1
Department of Oral and Maxillofacial
Surgery, Royal Shrewsbury Hospital,
Shrewsbury, UK; 2Department of

vascular calcification Otolaryngology, Royal Shrewsbury Hospital,

Shrewsbury, UK

complicating microvascular
surgery
B. Castling, S. Bhatia, F. Ahsan: Mönckeberg’s arteriosclerosis: vascular
calcification complicating microvascular surgery. Int. J. Oral Maxillofac. Surg. 2014;
xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. 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, Key words: Mönckeberg’s arteriosclerosis;
we would suggest that unlike vessels affected by atherosclerosis, anastomosis of microvascular surgery.
arteries affected by Mönckeberg’s arteriosclerosis has little or no impact on free flap
survival. Accepted for publication 13 October 2014

Mönckeberg’s arteriosclerosis is a form of calcification of the tunica media of small- affected vessel. Despite this, such vessels
vessel hardening in small- and medium- and medium-sized arteries, particularly in deliver relatively normal distal perfusion,
sized arteries as a result of tunica media the forearms and legs, together with an indeed there is often a bounding pulse at
calcification (Fig. 1). It is often an inci- absence of lumenal narrowing and intimal the end of the calcified zone. Described
dental finding, identified either clinically disruption.1 The venous system, lacking a clinically as ‘pipe-stem’ arteries, this is
or on plain radiography, and can occasion- thick muscular media, remains unaffected. visible on plain radiographs as ‘rail-track-
ally be associated with diabetes mellitus or Although clinically asymptomatic it pre- ing’ of the vessel. They appear unremark-
chronic kidney disease. Its distinctions sents strikingly as hard, pulseless calcifi- able on magnetic resonance angiography.
from atherosclerosis are the striking cation, often throughout the length of the This condition although relatively rare

0901-5027/000001+03 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Castling B, et al. Mönckeberg’s arteriosclerosis: vascular calcification complicating microvascular
surgery, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.10.011
YIJOM-3019; No of Pages 3

2 Castling et al.

(0.6% of the population) has and will

dissuade microvascular surgeons from
using such vessels for free flap reconstruc-
tion.2 We present our experience of such a
case and a review of the literature.

Case report
A 64-year-old man presented with a T4N0
squamous cell carcinoma of the alveolus
of the left body of the mandible. He was a
non-smoker and was diagnosed with atrial
fibrillation in the surgical work-up. He had
Fig. 1. Cross-section through a medium-sized artery, showing calcification (dark purple) in the
had previous lower spinal surgery through
tunica media and an intact tunica intima. (For interpretation of the references to colour in this
figure legend, the reader is referred to the web version of this article.) an anterior trans-iliac approach. His lower

Fig. 2. Radiograph of the forearm used for the osseocutaneous radial forearm free flap, demonstrating ‘rail-tracking’ of the calcified radial artery
(white arrows).

Please cite this article in press as: Castling B, et al. Mönckeberg’s arteriosclerosis: vascular calcification complicating microvascular
surgery, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.10.011
YIJOM-3019; No of Pages 3

Mönckeberg’s arteriosclerosis 3

legs were cold and hairless, with diminu- Discussion would not preclude its use in microvascu-
tion of the pedal pulses and mild pitting lar anastomosis.
oedema. A surgical plan of segmental Although Mönckeberg’s arteriosclerosis is
resection was planned and a magnetic a relatively rare entity, we believe it is a Funding
resonance angiogram of his lower legs condition that many microvascular sur-
arranged. This showed bilateral stenosis geons will come across in their practicing None.
of the anterior tibial vessels and taken with lifetime. It characteristically affects the ra-
the clinical findings precluded a fibula free dial arteries bilaterally, and although Competing interests
flap. In consultation with the anaesthetic asymptomatic, its clinical appearance is
team we planned for an osseocutaneous very striking. It is primarily a disease of None.
radial forearm free flap. Although the arteries, but associated soft tissue calcifica-
patient had a positive bilateral Allen’s test, tions have been reported, supporting a Ethical approval
the radial arteries were bony hard and unique pathogenesis.3 The condition has
Not required.
could be palpated throughout their fore- been described as creating a hardened wall
arm course. Plain radiographs of the through which a microvascular suture can-
forearm confirmed ‘rail-tracking’ calcifi- not pass and would thus lead to unsuccessful Patient consent
cation of these vessels, consistent with a anastomosis.2 Our experience with using Not required.
diagnosis of Mönckeberg’s arteriosclero- such an affected radial artery is that sutures
sis (Fig. 2). The anaesthetist did not feel will pass, and unlike diseased arterial
walls affected by traditional atherosclerosis, References
that the radial arteries could be cannulated
for the arterial line and sought an alterna- there is no tendency for intimal dehiscence, 1. Micheletti RG, Fishbein GA, Currier JS, Fish-
tive site. Supported by the positive Allen’s wall tearing, or luminal narrowing. bein MC. Mönckeberg’s sclerosis revisited: a
test we opted to use the non-dominant We would caution that this condition clarification of the histological definition of
forearm for our flap. can appear undetected on magnetic reso- Mönckeberg’s sclerosis. Arch Pathol Lab Med
Dissecting out the calcified radial ar- nance angiogram and can co-exist with 2008;132:43–7.
tery was akin to dissecting out a hard more common atherosclerosis. Therefore 2. Lin AC, Faquin WC, Deschler DG. Microvas-
chalk-like cord. The flap was raised, inset clinical examination findings are vital cular techniques for challenging vascular anat-
and the distal radial artery opened. The when assessing the risk of distal extremity omy: the reverse arterial flow technique.
wall was obviously heavily calcified, but ischaemia. Additionally it can be difficult ResearchPosters.com. http://www.researchpos-
to surgically compensate for vessel diam- ters.com/Posters/AAOHNSF/AAO2013/sp%
this held open a wide lumen with an
20213.pdf. (This was accessed on 01/08/2014).
otherwise healthy internal vessel wall. eter mismatch, as the calcified vessel wall
3. Couri C, da Silva G, Martinez J, Pereira Fde
There was no evidence of intimal dissec- is unyielding. The risk of vessel wall
A, de Paula FJ. Mönckeberg’s sclerosis—is
tion and a 9/0 vascular needle could pass splitting does, however, appear to be low. the artery the only target of calcification?
through the vessel wall. It was noted that Potentially an arterial vessel wall held BMC Cardiovasc Disord 2005;5:34.
because the radial artery wall was held rigidly open with an unblemished intima 4. Lee MK, Blackwell KE, Kim B, Nabili V.
rigidly open by the calcification, it was not can make for a technically easier anasto- Feasibility of microvascular head and neck
as easy to correct any circumferential mosis. In an extensive review of the fea- reconstruction in the setting of calcified arte-
mismatch in vessel lumen size. Good flow sibility of microvascular reconstruction in riosclerosis of the vascular pedicle. JAMA
was established at the first attempt, and an the setting of calcified arteriosclerosis, Facial Plast Surg 2013;15(March):135–40.
implantable Doppler probe was placed Lee et al. identified vascular pedicle cal-
distal to the anastomosis for postoperative cification in 44 out of 1329 cases (3%).4 Address:
monitoring. The procedure was complet- Eight of these patients (0.6%) were Brian Castling
ed and the patient recovered well. On day specifically recognized clinically and Department of Oral and Maxillofacial
5, the flap showed signs of venous con- radiographically to have Mönckeberg’s Surgery
arteriosclerosis. There were no total flap Royal Shrewsbury Hospital
gestion and the patient was returned to
Mytton Oak Road
theatre. The recipient vein had throm- failures in these patients. Our own expe- Shrewsbury SY38XQ
bosed and the venous anastomosis was rience with this condition would support a UK
revised. There was no problem with arte- similar approach, i.e. that if distal perfu- Tel.: +44 01743 261281;
rial inflow and the flap survived without sion is satisfactory, then calcification of a Fax: +44 01743 261366
further problem. vessel in Mönckeberg’s arteriosclerosis E-mail: [email protected]

Please cite this article in press as: Castling B, et al. Mönckeberg’s arteriosclerosis: vascular calcification complicating microvascular
surgery, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.10.011