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