A 62-year-old woman with a history of smoking presented to the emergency room complaining of acute onset of pain and color change of the left toes. All five of her toes turned purple-blue in color (Figure 8-1). The patient also reported a low-grade fever but denied any precipitating events. Her past medical history was significant for hypertension and coronary artery disease. Her feet were warm, and she had diminished bilateral femoral pulses and absent distal pulses on physical examination. Upon further questioning, the patient admitted to short-distance claudication.
Cyanotic toes in a 62-year-old female patient diagnostic of blue toe syndrome. (Reprinted by permission from Atheromatous embolization. Rutherford's Vascular Surgery. 7th ed. Philadelphia, PA: Elsevier Inc; 2010:2427.)
Computed tomographic arteriogram (CTA) showed severely calcified atherosclerotic disease of the abdominal aorta and iliac arteries (Figure 8-2).
Severely calcified aorta and bilateral iliac arteries (arrows).
The final diagnosis was of blue toe syndrome or atheromatous embolization secondary to severe atherosclerotic disease of abdominal aorta.
Usually affects elderly population with multiple risk factors for atherosclerosis, but it may occur in younger individuals with advanced atherosclerosis.
The incidence varies, based on population selection and diagnostic criteria. The unselected autopsy studies show that incidence is 0.85% to 2.4%.1,2, and 3 However, autopsy studies performed in selected patients with atherosclerosis and patients who had undergone aortic manipulation showed a prevalence ranging from 12% to 77%.4,5
There is an increased frequency in males. This may be explained by the difference in the prevalence of atherosclerosis between the genders.
Less likely to occur in blacks than in whites (32:1 ratio).1 This may represent failure to recognize the pathology because of skin pigmentation.
ETIOLOGY AND PATHOPHYSIOLOGY
The most important risk factor is established atherosclerosis.
This is a process in which emboli from proximal lesions (plaque) produce ischemia in distal arterial beds.
It may be associated with significant pain and risk of tissue loss such as gangrenous tissue changes (Figure 8-3).
Emboli may consist of thrombus, platelet-fibrin material, or a combination of both. Macroemboli may arise from thrombus originating in aortic or peripheral aneurysms or atheromatous ulcers, or from the dislodgement of atheromatous plaques. Microemboli are platelet-fibrin emboli or cholesterol crystals. Cholesterol crystals are lightweight and tend to be diffused and lodge in arteries as small as 100 to 200 μm.6,7
Factors that may precipitate lesion (plaque) instability and result in atheroembolization include trauma, vascular surgery, endovascular procedures such as cardiac catheterization, and anticoagulation. Spontaneous embolization was once the most common presentation. With the increase in endovascular ...
Log In to View More
If you don't have a subscription, please view our individual subscription options below to find out how you can gain access to this content.
Want remote access to your institution's subscription?
Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.
If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.
AccessCardiology Full Site: One-Year Subscription
Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.
Pay Per View: Timed Access to all of AccessCardiology
24 Hour Subscription $34.95
48 Hour Subscription $54.95
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.