Blue Toe Syndrome

13 Sep

•When atherosclerotic plaques rupture, they can develop either thromboemboli, made of clot, or atheroemboli, made of cholesterol crystals.

Atheroemboli are rarer, smaller and more likely to occlude smaller arteries, more often associated with a shower of microembolic over time, rather than the acute release of one or a few thromboemboli acutely, which cause severe ischemic events. Atheroembolic events probably do occur frequently but on a subclinical scale.




Clinical presentation can include renal failure, mesenteric ischemia, blue toe syndrome, or livedo reticularis (see picture) due to emboli from descending thoracic or abdominal aorta, or microvascular cerebral infarcts due to emboli from the ascending aorta



•Etiology can be spontaneous, or as a complication of cardiac catheterization or vascular surgery, angioplasty, angiography, or cardiac surgery

•Dermatologic manifestations usually involve the lower extremities, and can range from livedo reticularis to purpura to ulcerations to gangrene. The phrase “Blue toe syndrome” was first used to describe this dermatologic manifestation in patients with cholesterol embolization syndrome, but other causes of purplish discoloration of the toes need to be excluded.

Peripheral pulses are usually present, since only smaller arteries are typically affected.


Diagnosis: May see leukocytosis, elevated ESR and CRP. TEE, CT, and MRI are the modalities of choice to identify the aortic plaques

Biopsy of the affected skin or damaged end organ is the only definitive diagnosis


Treatment: Aortic bypass or endarterectomy, or endovascular stent graft placement


Submitted by M. Smith.


References: Kronzon I, Saric M. Cholesterol Embolization Syndrome. Circulation. 2010;122:631-641.; Saric M, Kronzon I. Aortic Atherosclerosis and embolic events. Curr Cardiol Rep. 2012 Jun;14(3):342-9.; livedo reticularis picture; blue toe picture


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