Vascular Disease

Radiographic pathology associated with diabetes includes:

Differential Diagnosis of Mönckeberg's Sclerosis

Other soft tissue calcifications include:

Here are classic presentations of vessel calcification:

  • Case 1
  • *Case 1
  • Case 2
  • *Case 2
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
DP Medial arterial calcification

DP Medial arterial calcification

DP view. Tubular, serpiginous calcification lateral to the hallux proximal phalanx.. (Trivia: Some people have referred to it as similar in appearance to "railroad tracks" and a "gooseneck lamp".) Other findings include increased soft tissue density and volume throughout the hallux; osteophytes at the medial and lateral margins of the first metatarsophalangeal joint. Diagnoses: Mönckeberg's sclerosis, osteoarthritis, soft tissue infection (clinical diagnosis).

Lateral medial arterial calcification

Lateral medial arterial calcification

Lateral view. Tubular, serpiginous calcifications (t) anterior and posterior to the ankle. Incidental findings: spurs (s) along the inferior and posterior calcaneal surfaces; bone hypertrophy (h) and a large ossicle(O) along the posterior-superior aspects of the posterior calcaneus. Diagnoses: Mönckeberg's sclerosis, enthesopathy, Haglund's deformity, and post-traumatic Achille's tendon ossification.

Atheromas

Atheromas

Patchy, solid calcifications (arrows) are seen lateral to the first metatarsal base and shaft. Diagnosis: Atherosclerosis (atheromas)..

Phleboliths

Phleboliths

Oval-shaped or circular calcifications with a lucent center (arrows) can be seen anterior to the leg. Diagnosis: phleboliths.

Should a radiographic study be ordered for vascular calcification alone?

No. Moenckeberg's sclerosis is commonly associated with diabetes, but typically is an incidental finding. It represents calcification of the tunica media layer of an artery; the calcification is not located in the lumen and does not impair blood flow. It's presence interdigitally can aid in the diagnosis of diabetes in clinically unsuspected patients.

What are the best views to order?

DP and lateral views are sufficient.

Other information

Diabetic patients with MAC are at significant excess risk for total mortality, stroke mortality and cardiovascular mortality than patients without diabetes.

The predominance of peripheral arterial occlusive disease in the lower leg (versus the upper leg) of diabetic patients appears to be related to the presence of forefoot MAC.

Many believe that MAC does not also involve the internal elastic lamina (IEL) and, therefore, does not pose a threat to circulation. However, there has been histopathologic disagreement since J.G. Monkeberg's original article in 1903 whether or not both the media and the IEL are involved in MAC. If indeed the IEL is involved, then decreased arterial compliance should be a consideration.

References:

  1. Rennenberg RJMW, Schurgers LJ, Kroon AA, Stehouwer CDA: Arterial calcifications. J. Cell. Mol. Med. Vol 14, No 9, 2010 pp. 2203-2210
  2. Chantelau E, Lee KM, Jungblut R: Association of below-knee atherosclerosis to medial arterial calcification in diabetes mellitus. Diabetes Research and Clinical Practice 29 (1995) 169-172
  3. Micheletti RG, Fishbein GA, Currier JS, Fishbein MC: Mönckeberg Sclerosis Revisited - A Clarification of the Histologic Definition of Mönckeberg Sclerosis. Arch Pathol Lab Med 2008;132:43–47.