Abstract

Introduction: A wide spectrum of vascular calcification is known.

Aim of the Study: The aim of this study was to identify and characterize the major categories of arterial calcifications (AC): the atherosclerotic intimal calcification (Ath), and the artery calcification of Mönckeberg (MSc).

Patients and Methods: Characteristics of arterial calcification and crystal deposits were analyzed in 67 consecutive amputated lower limbs of 45 patients. One or both legs of patients were amputated, sometimes repeatedly at different levels.

The standard staining and reaction (H-E, Alizarin red, and von Kossa) were compared with unstained sections according to Bély and Apáthy (2013). This new, very sensitive method is suitable to identify cholesterol, hydroxyapatite (HA), calcium pyrophosphate dihydrate (CPPD), monosodium urate crystals, etc. in formalin fixed, paraffin embedded, unstained tissue sections viewed with polarized light.

Results: The mean age of the patients with atherosclerosis was significantly higher, than the mean age of patients with Mönckeberg sclerosis, but the difference was not as large as mentioned in the pertinent literature.

Between the two patient cohorts there was no significant difference in prevalence of arterial calcification and bone formation with or without true medullar spaces, but there were discrepancies in presence of crystals.

Discussion and Conclusion: Atherosclerosis and Mönckeberg sclerosis are different entities, characterized by cholesterol crystal deposition in Ath, and HA crystal deposition (with or without CPPD) in MSc. Overlaps between Ath and MSc are plausible.

Atherosclerosis is related to elevated low density lipoprotein concentration in blood, and Mönckeberg sclerosis may be consequence of a complex genetically determined metabolic disorder, a crystal induced angiopathy.

Bély and Apáthy’s “non-staining” technique is a useful method to distinguish atherosclerosis and Mönckeberg sclerosis.

Keywords: Atherosclerosis; Mönckeberg Sclerosis; Cholesterol; Hydroxyapatite; Calcium Pyrophosphate Dihydrate Crystals

References

1. Albanese I., et al. “Atherosclerotic Calcification: Wnt Is the Hint”. Journal of the American Heart Association (JAHA) 7.4 (2018).
2. Demer LL and Tintut Y. “Vascular Calcification Pathobiology of a Multifaceted Disease”. Circulation 117 (2008): 2938-2948.
3. Baumer Y., et al. “Hyperlipidemia-induced cholesterol crystal production by endothelial cells promotes atherogenesis”. Nature Communications 8 (2017): 1129.
4. Grebe A and Latz E. “Cholesterol crystals and inflammation”. Current Rheumatology Reports3 (2013): 313.
5. Deneke T., et al. “Ossification in atherosclerotic carotid arteries”. Zeitschrift für Kardiologie3 (2001): 106-115.
6. Hunt JL., et al. “Bone Formation in Carotid Plaques A Clinicopathological Study”. Stroke 33 (2002): 1214-1219.
7. Nasir K., et al. “Ethnic differences between extra-coronary measures on cardiac computed tomography: multi-ethnic study of atherosclerosis (MESA)”. Atherosclerosis 1 (2008): 104-114.
8. Mönckeberg JG. “Über die reine Mediaverkalkung der Extremitätenarterien und ihr Verhalten zur Arteriosclerose. Virchows Archiv für pathologische Anatomie und Physiologie, und für klinische Medicin 171 (1903): 141-167.
9. Lanzer P., et al. “Medial vascular calcification revisited: review and perspectives”. European Heart Journal23 (2014): 1515-1525.
10. McCullough PA., et al. “Accelerated atheroslerotic calcification and Mönckeberg’s sclerosis: A continuum of advanced vascular pathology in chronic kidney disease”. Clinical Journal of the American Society of Nephrology6 (2008): 1585-1598.
11. Leiber B and Olbrich G. “Mönckeberg‘ syndrome”. In Wörterbuch der klinischen Syndrome, Urban und Schwarzenberg, München, Berlin, Germany, Editors: Leiber B, Olbrich G (1963): 413.
12. Bély M and Apáthy A. “Mönckeberg-sclerosis – kristály indukálta angiopathia. (Mönckeberg’s sclerosis – crystal induced angiopathy)”. Orvosi Hetilap23 (2013): 908-913.
13. Bély M and Apáthy A. “Functional Role of Hydroxyapatite Crystals in Monckeberg's Arteriosclerosis”. Journal of Cardiovascular Disease (JCvD)5 (2014): 228-234.
14. Quaglino D., et al. “The biology of vascular calcification”. International Review of Cell and Molecular Biology 354 (2020): 261-353.
15. Carson FL. “Mayer’s hematoxylin”. In Histotechnology, ASCP Press: Chicago, Editor: Carson FL (1990): 100-103.
16. McManus JFA and Mowry RW. “Methods of general utility for the routine study of tissues”, “Sodium Alizarin sulfonate stain for calcium” and “Von Kossa’s method for phosphates and carbonates”. In Staining methods, histologic and histochemical, Hoeber PB Inc, New York, Editors: McManus JFA, Mowry RW 55-72 (1960): 193-194.
17. Vacca LL. “Alizarin red S”. In Laboratory manual of histochemistry, Raven Press, New York, Editor: Vacca LL (1985): 333-334.
18. Lillie RD. “Von Kóssa’s method”. In Histopathologic technic and practical histochemistry, The Blakiston Division McGraw-Hill Book Company, New York, Toronto, London, Editor: Lillie RD (1954): 264-265.
19. Bély M and Apáthy Á. “A Simple Method of Diagnostic Pathology for Identification of Crystal Deposits in Metabolic and Crystal Induced Diseases”. Structural Chemistry and Crystallography Communication115 (2016): 1-6.
20. Bély M and Apáthy A. “Metabolic Diseases and Crystal Induced Arthropathies Technic of Non-Staining Histologic Sections - A Comparative Study of Standard Stains and Histochemical Reactions”. Clinical Archives of Bone and Joint Diseases (2018): 1.2.
21. Bély M and Apáthy A. “Crystal deposits in tissue of patients with chondrocalcinosis and apatite rheumatism – Microscopic identification of CPPD and HA with the non-staining technique of Bely and Apáthy. BAOJ Clinical Trials 4 (2018): 018.
22. Bély M and Krutsay M. “A simple method to demonstrate urate crystals in formalin fixed tissue”. Journal of Autoimmune Diseases and Rheumatology (JADR) 1 (2013): 46-49.
23. Lentner C. “Statistical methods”. In Geigy scientific tables, 8^th revised and enlarged ed: Ciba-Geigy Limited, Basle, Switzerland, Editor: Lentner C, Compiled by: Diem K, Seldrup J 2 (1982): 227.
24. Crowford T. “Arterics, veiens and lymphatics: hypertension” In Systemic pathology, 2^nd edition: Churchill Livingstone, Edinburgh, London, New York, Editor: Symmers WStC 3 (1976): 122-123.
25. Amann K. “Media calcification and intima calcification are distinct entities in chronic kidney disease”. Clinical Journal of the American Society of Nephrology6 (2008): 1599-1605.
26. Couri CEB., et al. “Mönckeberg's sclerosis – is the artery the only target of calcification?’ BMC Cardiovascular Disorders 5 (2005): 34.
27. Rosenthal AK and Ryan LM. “Calcium Pyrophosphate Deposition Disease”. The New England Journal of Medicine 374 (2016): 2575-2584.
28. Dieppe PA., et al. “Apatite deposition disease. A new arthropathy”. Lancet 307 (1976): 266-269.
29. Halverson PB., et al. “Histopathological and ultrastructural studies of synovium in Milwaukee shoulder syndrome-a basic calcium phosphate crystal arthropathy”. Annals of the Rheumatic Diseases5 (1984): 734-741.
30. Gardner DL and McClure J. “Metabolic nutritional and endocrine diseases of connective tissue, Crystal deposition disease, Calcium pyrophosphate dihydrate crystal deposition disease (chondrocalcinosis; pseudogout), Calcifying tenosynovits, Calcium hydroxyapatite and articular disease”. In Pathological basis of the connective tissue diseases, 1st ed.: Edward Arnold, London, Melburne, Auckland, Great Britain, Editor: Gardner DL 10 (1992): 393-402.
31. Mohr W Gicht. “Kalziumpirophosphat-Arthropathie“, “Apatitkrankheiten“. In Gelenkpathologie, historische Grundlagen, Ursachen und Entwicklungen von Gelenkleiden und ihre Pathomorphologie, Berlin, Heidelberg, Springer-Verlag, Germany, Editor: Mohr W (2000): 193-201.
32. Reginato AJ ans Reginato AM. “Diseases associated with deposition of calcium pyrophosphate or hydroxyapatite”. In Crystal-associated synovitis, Section XV, Kelly’s Textbook of Rheumatology, 6^th WB Saunders Company: A division of Harcourt Brace and Company, Philadelphia, London, New York, St. Louis, Sydney, Toronto, Editors: Ruddy Sh, Harris ED jr, Sledge CB 89.90 (2001): 1377-1390.
33. Fassbender HG. “Crystal induced arthropathies, Calcium pyrophosphate dihydrate crystal deposition disease, Hydroxyapatite crystal deposition disease”. In Pathology and pathobiology of rheumatic diseases, 2^nd Berlin, Heidelberg, New York, Springer-Verlag, Germany, Editor: Fassbender HG 17 (2002): 370-376.
34. Gupta SJ. “Crystal induced arthritis: an overview. INJR (Indian Journal of Rheumatology – formerly”. Journal of Indian Rheumatology Association 10 (2002): 5-13.
35. Pearse AGE. “Hexamine silver method for uric acid”. In Histochemistry theoretical and applied, Churchill Livingstone, Edinburgh, London, Melbourne and New York, Editor: Pearse AGE (1985): 1012-1026.
36. Balogh K. (Personal communication (2013).
37. Gatter RA and Schumacher HR. “A practical handbook of joint synovial fluid analysis”. 2^nd edition: Lea and Febiger, Philadelphia, London (1991): 46.
38. Swan A., et al. “Submicroscopic crystals in osteoarthritic synovial fluids”. Annals of the Rheumatic Diseases7 (1994): 467-470.
39. Pay S and Terkeltaub R. “Calcium pyrophosphate dihydrate and hydroxyapatite crystal deposition in the joint: New developments relevant to the clinician”. Current Rheumatology Reports3 (2003): 235-243.
40. Bély M and Balogh K. “Calcification and crystal deposition of aortic valves in clinically latent metabolic disease – A case report”. EC Cardiology6 (2021): 40-47.