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Blue Toe Syndrome

An article from the e-Journal of Cardiology Practice

Blue toe syndrome is one of the frequent manifestations of tissue ischaemia. It is caused by the occlusion of small vessels, and usually occurs in elderly men who undergo an invasive vascular procedure. Clinical manifestations of blue toe syndrome range from an isolated blue ischemic toe to a diffuse multiorgan systemic disease. The treatment consists of surgical or percutaneous elimination of the source of embolisation. Medical treatment is mostly symptomatic.

Blue toe syndrome is characterised by tissue ischaemia secondary to cholesterol crystal or atherothrombotic embolisation. It leads to the occlusion of small vessels. Cyanosis of the digits may have several etiologies ranging from trauma to connective tissue disease. However, the most common cause of blue toe syndrome is atheroembolic disease or aneurysm. Embolisation occurs typically following an ulcerated atherosclerotic plaque or aneurysm located in the aorto-iliac-femoral arterial system. Embolisation can occur spontaneously or due to a variety of causes. Most often, microembolisation appears in elderly men who have undergone an angiographic procedure or vascular surgery or even anticoagulant or thrombolytic treatment. (1, 2) The differential diagnosis of blue toe syndrome (especially secondary) includes Raynaud’s  phenomenon. In Raynaud’s syndrome, ishaemic lesions are usually more diffuse, larger areas of distal parts of different fingers (rarely toes) are involved and are affected by vasospastic disorders. The patients are usually younger and without any known atherosclerotic disease. In blue toe syndrome, skin lesions are usually restricted and related to the occluded artery: fingers are rarely affected as opposed to toes, and vasospasm is usually absent. Painful red, purple, blue or black toes can also be seen in patients with thrombocythemia associated with polycythemia vera or in essential thrombocythemia. (3) In these patients, ischemic lesions of fingers or toes are caused by arteriolar inflammation and the thrombosis of microvessels that appear as a consequence.
The syndrome of cholesterol embolism is often a multiorgan disorder. Clinical presentation can range from a cyanotic toe or livedo reticularis to a diffuse multiorgan systemic disease that can mimic other systemic illnesses. Mild forms of the disease have a good prognosis and subside without sequelae. However, diffuse multisystemic forms have a very poor prognosis. The kidney is the organ that is most often affected (in approximataly 50% of cases). In the systemic form, prognosis is poor with a mortality rate of about 70%. (4)
Blue toe syndrome is frequently misdiagnosed on initial presentation. Pedal pulses are often palpable, which may misdirect the physician from a diagnosis of vascular pathology. The differential diagnosis can be divided into three categories: emboli from the cardiac and arterial system, acquired hypercoagulability disorders, and syndromes that lead to peripheral vascular pathology. Non-invasive vascular testing, peripheral angiography, abdominal and popliteal ultrasonography and echocardiography may be useful in discovering the origin of emboli. Recently, transesoephageal echocardiography and MRI have been shown to be a helpful tool in imaging the thoracic aorta and greatly detailed delineating of the anatomy of the aortic atheroma. (5) Diagnosis is usually (definitely) confirmed with skin or muscle biopsy and fundoscopic examination presenting cholesterol crystals.

At present, surgery (endartectomy or bypass with exclusion of the source of emboli) remains the most viable treatment option for patients with aneurysms. In all other patients, surgery is rarely indicated because the origin of cholesterol crystal embolisation is not certain and patients are usually too weak for a major surgical intervention. In some of these cases, endovascular procedures (angioplasty with stenting or endoprosthesis) can substitute reconstructive surgery in eliminating the source of embolisation. (6, 7)
Medical treatment is mostly symptomatic: rest, warm condition, appropriate dressing, hydration, and organ support when necessary, principally to ensure renal function. Treatment of pain that is usually disproportionate to the extension of tissue lesion is of utmost importance. Because these patients usually have advanced atherosclerotic disease, secondary prevention with elimination of risk factors of atherosclerosis is mandatory. Antiplatelet drugs represent one of the basic treatment options of blue toe syndrome. (8) The complete relief of pain and restoration of circulation is also obtained by  administration of aspirin in ischaemic complications of polycythemia vera complete. (3) Vasodilator drugs, including alpha-1 blocking agents that are usually used for the treatment of vasospastic disorders, have no proven efficacy in blue toe syndrome. In diffuse and multivisceral embolisation, either colchicine or corticosteroids adjuvant therapy may be useful. According to our experience, prostanoid drugs are also effective in treating ischaemic lesions caused by microembolisation. In the future, large randomised studies will be needed to help predict embolisation and, thus, decide on the proper medical therapy.

The content of this article reflects the personal opinion of the author and is not necessarily the official position of the European Society of Cardiology.


1. Applebaum R. M., & Kronzon I. Evaluation and management of cholesterol embolization and the blue toe syndrome. Curr Opin Cardiol, 1996. 11: 533-42.

2. Caldwell B. D., & Marrochello V. S. Microembolization from atheroembolic disease or aneurysm. A case study. J Am Podiatr Med Assoc, 1996. 86: 249-52.

3. Michiels J. J., Berneman Z., Schroyens W., & Urk H. Aspirin-responsive painful red, blue, black toe, or finger syndrome in polycythemia vera associated with thrombocythemia. Ann Hematol, 2003. 82: 153-9.

4. Wingo J. P., Nix M. L., Greenfield L. J., & Barnes R. W. The blue toe syndrome: hemodynamics and therapeutic correlates of outcome. J Vasc Surg, 1986. 3: 475-80.

5. Blackshear J. L., Oldenburg W. A., & Cohen M. D. Making the diagnosis when the patient has 'blue toes'. Geriatrics, 1994. 49: 37-9, 43-5.

6. Renshaw A., McCowen T., Waltke E. A., Wattenhofer S. P., Tahara R. W., & Baxter B. T. Angioplasty with stenting is effective in treating blue toe syndrome. Vasc Endovascular Surg, 2002. 36: 155-9.

7. Matchett W. J., McFarland D. R., Eidt J. F., & Moursi M. M. Blue toe syndrome: treatment with intra-arterial stents and review of therapies. J Vasc Interv Radiol, 2000. 11: 585-92.

8. Vayssairat M., Chakkour K., Gouny P., & Nussaume O. Atheromatous embolisms and cholesterol embolisms: medical treatment. J Mal Vasc, 1996. 21: 97-9.


Notes to editor

Prof. P. Poredos
Ljubljana, Slovenia
Vice-chair of the ESC Working Group on Peripheral Circulation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.