Blue toe syndrome: treatment with anticoagulants and delayed percutaneous transluminal angioplasty

Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report

Background

Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF.

Case presentation

A 65-year-old man presented with a two-day history of progressive painful swelling and bluish-purple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation.

Conclusion

The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.

Atheromatous embolization

Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.

Distal Peripheral Microembolism

Distal peripheral microembolism is caused by embolization of atherosclerotic debris into small arteries and arterioles. The recent advances in endovascular technique have been met with a gradual increase in the incidence of iatrogenic atheroembolism. This review seeks to explore the nature of distal peripheral microembolism, pathophysiology, and the management options, with a focus on iatrogenic distal peripheral microembolism.

New microembolus size estimator for peripheral blood vessels

Several factors affecting the power of Doppler scattered signal and, consequently, microembolus size estimation, may be eliminated when assessing the microembolus size via multiple measurements. A new microembolus size estimator is proposed based on the ratio of microembolus scattering cross-section in two directions and for two emission frequencies. Theoretical considerations indicate that the estimation of size of microembolic elements should be independent of the spatial distribution of the wave intensity, tissue attenuation and hardware factors. The simulation results indicate that this estimation only slightly depends on the material of the microembolus and acoustic properties of blood. The experimental results indicate that the accuracy of median size estimation increases with microembolus size. The measurement error is less than 27% for microemboli with median diameter larger than 360 μm. The method is constrained to the estimation of microembolus size in the vessels of extremities.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: Results after a mean of 15 months follow-up

BACKGROUND

Endovascular stent-graft (ESG) repair of abdominal aortic aneurysm (AAA) has emerged as an alternative to open surgery. The role of ESG in patients with challenging medical and anatomic problems remains an area of general debate. This study reviews an experience with stent grafts to treat patients with AAA and atheromatous embolization syndrome (AES) presenting with chronic distal embolization (CDE).

METHODS

Over a 5-year period 660 patients with AAA were treated with aortic stent grafts. Patients with AAA and ischemic ulcerations or toe gangrene due to CDE despite palpable foot pulses were investigated for successful aneurysm exclusion, resolution of ischemic symptoms, complications and survival. Follow-up averaged 15.3 +/- 14.9 months (range, 1 to 60 months).

RESULTS

Nineteen patients had AAA and manifestations of CDE. The population (16 males/3 females) had a mean age of 79 +/- 7 years and mean aneurysm diameter of 5.5 cm. Renal insufficiency was present in 5/19 (26 %). Ischemia presented as ischemic ulcers (16/19 [84.2%]) or toe gangrene (3/19 [15.8%]). Stent grafts included 6 aortouniiliac and 13 bifurcated devices. Exclusion was achieved in all but 2 patients who had type II lumbar endoleaks. At 30-day postoperative follow-up, mortality was 0 % and resolution of CDE/ischemia was noted in 2 of 19 (10.5%) patients. Eight of 9 patients with follow-up of 1 year had complete resolution of their ischemic symptoms, with no recurrent manifestations of AES. Complications included progression of renal insufficiency over an 18-month period in 1 patient and an unstable expanding pararenal aortic neck in 1 patient. Foot ischemia persisted at 1 year in a patient with severe coexisting thoracic aortic disease despite successful AAA exclusion. Six (31.6%) patients died during a mean follow-up of 15.3 months from causes unrelated to their AAA.

CONCLUSION

On the basis of this experience, stent-graft repair of AAA and CDE may be an effective strategy to prevent future embolization. Recognition of coexisting thoracic aortic disease is essential. ESG does not address the extremely high morbidity and mortality from cardiovascular causes in this population.

Treatment of embolizing arterial lesions with endoluminally placed stent grafts

The purpose of this study was to demonstrate the safety and efficacy of endovascular stent grafts for the management of embolizing arterial lesions. Eight patients who presented to Barnes-Jewish Hospital between June 2000 and June 2001 with embolizing arterial lesions were treated with covered stents or stent grafts. All hospital records were retrospectively reviewed, and pertinent data extracted. Our results showed that endovascular stent grafts can be used successfully to exclude embolizing arterial lesions without increasing the risk of further embolization. Long-term follow-up will be necessary to assess the durability of this approach to embolizing arterial lesions.

Late complication of aortoiliac stent placement- atheroembolization of the lower extremities

BACKGROUND

Atheroembolization following aortoiliac stent placement is uncommon. The purpose of this study was to examine the management and risk factors of lower extremity atheroembolization following aortoiliac stent placement for occlusive disease.

MATERIALS AND METHODS

From March 1993 to February 2001, the hospital records of all patients who developed thromboembolic events following aortoiliac stent placement were reviewed. Risk factor analysis was performed by comparing with the control group, which consisted of 493 patients treated with aortoiliac stents during the study period who did not develop atheroembolic complications. Patients with cardiac etiologies or aortic aneurysms as the source of embolization as well as those who developed acute embolization following stent deployment (<30 days) were excluded.

RESULTS

Atheroembolization occurred in eight patients (12 iliac artery stents and 1 aortic stent) at intervals ranging from 9 to 43 months (mean 22 months) following aortoiliac stent placement. Arteriography in all patients implicated the stented artery as the source of atheroembolism. Five corrective operations (two aorto-bifemoral bypasses, one ileofemoral bypass, and two aortoiliac endarterectomies) along with two concomitant femoropopliteal thrombectomies were performed successfully in five patients. The remaining three patients were treated with either thrombolysis and/or additional stent placement, which resulted in either iliac occlusion or recurrent embolic symptoms (P < 0.05). All 3 patients subsequently underwent bypass procedures (one ileofemoral and two femorofemoral bypasses). There was no perioperative mortality. During a mean follow-up of 16 months (range 3 to 45 months), two patients required minor amputations, whereas one required major leg amputation. No further episodes of atheroembolism occurred in the involved limbs following surgical bypass procedures. Risk factor analysis failed to identify potential variables that correlated with atheroembolism following aortoiliac stent placement.

CONCLUSION

Patients with atheromatous embolization following aortoiliac stent placement should be evaluated aggressively. The treatment of choice is surgical correction or bypass with exclusion of the offending embolic source. Although intra-arterial stent placement in the atheroembolic stented iliac artery is feasible, it may provide a less durable result.

Early experience using the Wallgraft in the management of distal microembolism from common iliac artery patholology

Blue toe syndrome commonly occurs as a result of aneurysmal or atherosclerotic disease in the iliac arteries. Surgery, angioplasty, or intraarterial stent placement are the most common treatment options but the optimal management has not been defined. Here we report managing distal microembolization from iliac artery atherosclerosis associated with aneurysmal dilation with the Wallgraft Endoprosthesis, a self-expanding metallic stent covered with Dacron. Three common iliac arteries in two patients were treated using this device. A 79-year-old male presented with unilateral symptoms and an 83-year-old female with bilateral disease. Arteriography demonstrated complex plaque at the aortic bifurcation associated with aneurysmal dilation of the distal common iliac artery in both patients. This complex disease was successfully covered using the Wallgraft Endoprosthesis. Postoperatively the patients received aspirin, their toe lesions healed, and neither has had a recurrence after 16 months. Covered stents offer the theoretic advantage of completely excluding the diseased segment, preventing the escape of thrombus or plaque debris, and covering aneurysmal dilation in the artery.

Blue toe syndrome: treatment with intra-arterial stents and review of therapies

PURPOSE

To determine if intra-arterial stent placement can adequately treat lesions producing microemboli to the lower extremities.

MATERIALS AND METHODS

During a 6.5-year period, 15 patients presenting with blue toe syndrome had 16 presumed embolic lesions treated with intra-arterial stents. These patients were evaluated during routine clinical follow-up during a 6-month period. This evaluation included physical and noninvasive arterial examinations. When patients could not return for follow-up, hospital, clinical, vascular laboratory, and radiology records were reviewed to assemble the appropriate information. Outcomes included symptoms of recurrent emboli, amputation, and death.

RESULTS

Treated embolic lesions included two aortic stenoses, three bilateral iliac artery stenoses, nine unilateral iliac artery stenoses (one patient received separate treatment of unilateral iliac lesions), and two superficial femoral artery stenoses. Patients were followed-up for a mean of 18 months. Eight of 15 patients (53%) were improved or stable without complications. There were eight negative outcomes experienced in seven patients. Three patients (20%) were deceased at follow-up. Four patients (27%) had undergone amputation; one transmetatarsal amputation and three below-the-knee amputations. Only one of these was related to progressive disease in the treated extremity (7%). One patient (7%) experienced recurrent embolic symptoms. Stents were patent in all patients.

CONCLUSION

Patients with blue toe syndrome are at high risk of limb loss and mortality despite treatment. Intra-arterial stent placement provides an alternative to standard surgical treatment. Further studies are needed to define the optimum therapy.

The endovascular management of blue finger syndrome

OBJECTIVES

To review our experience of the endovascular management of upper limb embolisation secondary to an ipsilateral proximal arterial lesion.

DESIGN

A retrospective study.

MATERIALS AND METHODS

Over 3 years, 17 patients presented with blue fingers secondary to an ipsilateral proximal vascular lesion. These have been managed using transluminal angioplasty (14) and arterial stenting (five), combined with embolectomy (two) and anticoagulation (three)/anti-platelet therapy (14).

RESULTS

All the patients were treated successfully. There have been no further symptomatic embolic episodes originating from any of the treated lesions, and no surgical amputations. Complications were associated with the use of brachial arteriotomy for vascular access.

CONCLUSIONS

Endovascular techniques are safe and effective in the management of upper limb embolic phenomena associated with an ipsilateral proximal focal vascular lesion.

Young women with advanced aortoiliac occlusive disease: new insights

We identified a group of 24 young (less than 50 years of age) women with isolated, premature atherosclerotic aortoiliac occlusive disease and attempted to identify distinguishing hemostatic characteristics. Most of these patients (62%) presented with acute thromboembolic events (blue toe syndrome, n = 6; macroemboli, n = 6; or aortoiliac thrombosis, n = 3). Aortoiliac reconstruction (aortoiliac endarterectomy, n = 10, aortobifurcation bypass grafts, n = 6; and percutaneous angioplasty, n = 4) was complicated by early thrombosis in 6 of 20 cases (30%), (1 of 10 endarterectomies, 4 of 6 bypass grafts, and 1 of 4 angioplasties). Fresh thrombus overlying an atherosclerotic plaque was a common finding at surgery. This observation and the relatively high incidence of thromboembolic events led us to hypothesize that a characteristic hemostatic profile might underlie the remarkably similar clinical presentations of these women. Levels of antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), plasminogen activator inhibitor-1, fibrinogen, antithrombin III, protein C, protein S, plasminogen, prothrombin fragment F1 + 2, and D-dimer were determined for these young women and for 21 age-matched white female control subjects without vascular disease and nine white male patients with aortoiliac occlusive disease (mean 61 years, range 43 to 74 years). The incidence of anticardiolipin antibodies was 42% (8 of 19) in the female patients, which was significantly elevated (p = 0.028). The female (62.5%) and male (100%) patients had significantly elevated D-dimer levels (p < 0.001). Deficiencies of antithrombin III, protein C, and protein S were rare. A unique pattern of premature aortoiliac atherosclerosis exists in some young women. Intra-arterial thromboembolic events are common at presentation and complicate surgical management. The role of antiphospholipid antibodies remains uncertain.

An institutional experience with arterial atheroembolism

Seemingly minor blue-toe lesions resulting from atheroemboli are associated with unstable atherosclerotic plaques, which are at risk for causing recurrent emboli, tissue loss, and potentially death. At Washington University Medical Center, 62 patients (31 males and 31 females), ranging in age from 38 to 89 years (mean 62.8 +/- 11.7 years), were treated for cutaneous manifestations of atheroembolic disease. Most patients (62%) had spontaneous bouts of atheroembolism, but 13 (21%) had recently undergone an inciting invasive radiologic study, 10 (16%) were on anticoagulation therapy, and one (2%) experienced abdominal trauma. In addition to the cutaneous manifestations, 18 patients (29%) also developed coincidental deterioration in renal function and four (6%) had intestinal infarction from atheroemboli. Arteriography in nearly all patients (97%) implicated the aorta and iliac arteries most commonly (80%), with the femoral (13%), popliteal (3%), and subclavian (3%) arteries less frequently incriminated. Forty-two patients underwent bypass grafting procedures (36 anatomic and six extra-anatomic) after exclusion of the native diseased artery, 20 patients had endarterectomies (six with additional bypass grafts), and five patients had no corrective vascular procedures. The 30-day operative mortality rate was 5% in this series. Nineteen patients (31%) required minor amputations, whereas two required major leg amputations. Thus limb salvage was possible in 86 of 88 (98%) limbs. No further episodes of atheroembolism occurred in the involved limbs during follow-up (1 to 53 months, mean 20.2 months). We advocate urgent arteriography and surgical correction or bypass with exclusion of the offending lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin

We describe two patients with blue digit syndrome in whom transesophageal echocardiography was able to identify mobile thrombotic masses attached to the irregular intimal surface of the descending thoracic aorta. These patients were treated with heparin and warfarin and did not have recurrent episodes of peripheral arterial embolization. In this article we discuss the diagnostic and therapeutic approaches in patients with peripheral arterial embolization and blue digit syndrome.

Spontaneous peripheral arterial microembolization

Over a seven year period 52 patients having a clinical diagnosis of spontaneous peripheral arterial microembolization were identified. Sixty-one percent of patients were female, 15% were diabetic, and 73% used tobacco chronically. A striking finding was the very high incidence of associated systemic disorders such as thrombocytosis (8), polycythemia vera (3), metastatic adenocarcinoma (3), or collagen disease requiring steroid therapy (4). Forty-nine patients had significant proximal arterial lesions as the origin of their emboli. Three patients had digital ischemia as a result of increased platelet aggregation without arterial obstruction. Forty-eight patients underwent surgical therapy. Operative mortality was 4% and overall limb salvage in survivors was 96%. The clinical syndrome of arterial microembolization may result from several pathophysiologic mechanisms including cholesterol embolization from ulcerated plaques, fibrino-platelet aggregation in patients with hematologic disorders, or dislodgement of mural thrombus in those with aneurysmal disease. We observed aortoiliac disease to be more frequent than femoral-popliteal disease, and both were amenable to surgical correction. We conclude that the genesis of arterial microembolization is multifactorial and that a variety of systemic diseases may work in concert with atherosclerotic arterial disease to produce this clinical syndrome. Prompt recognition and appropriate treatment of this disorder can yield high rates of limb salvage.

Angioplasty of the terminal aorta: follow-up of 20 patients treated by PTA or PTA with stents

Twenty patients with distal aortic stenosis were treated by PTA for intermittent claudication and, in 3, 'blue toe' syndrome. Additionally, a self-expandable endoprosthesis (stent) was inserted into the aorta in three of the patients. The overall primary success rate (including those with a stent) was 100% with all patients becoming free of symptoms. Mean arm-ankle pressure difference decreased from 48 mmHg to 9 mmHg (P less than 0.01). During a median follow-up period of 15 months no patient had recurrence of claudication, embolism, or deterioration of the non-invasive parameters. Thus, PTA seems suitable for treating stenoses of the abdominal aorta, even in the presence of distal microembolization. Balloon dilatation, with the addition of stents in resistant cases, offers a valuable alternative to surgery in distal aortic stenosis.

Percutaneous transluminal angioplasty of the lower extremities by the vascular surgeon

As vascular surgeons, we performed 376 percutaneous transluminal angioplasties as follows: aorta and iliac arteries (148), infrainguinal arteries (191), and bypass grafts (21). Sixteen procedures were attempted but not completed. Neodymium-yttrium-aluminum-garnet laser thermoprobe was successfully used prior to balloon dilatations in 49 procedures. In contrast to our experience with operative intervention, percutaneous transluminal angioplasty was performed more frequently for claudication (75%), nondiabetics (72%), and women (45%). Median age was 71 years. Percutaneous transluminal angioplasty either preceded or followed proximal or distal open reconstruction in 58 extremities. Primary patency rates for iliac percutaneous transluminal angioplasties were: 94% at one month, 93% at six months, and 88% at one year. For infrainguinal percutaneous transluminal angioplasties they were 95%, 82%, and 70% at 1, 6, and 12 months, respectively. Repeat percutaneous transluminal angioplasty increased the one-year patency rates to 92% and 86% for iliac and infrainguinal percutaneous transluminal angioplasties, respectively. Preliminary data indicate that the six-month secondary patency rates were 82% for laser-assisted percutaneous transluminal angioplasty and 65% for percutaneous transluminal angioplasty of distal bypass grafts. The implementation of balloon angioplasty was facilitated by our 21 years of experience with arteriography. Percutaneous transluminal angioplasty has become a valuable adjunct to the practice of vascular surgery by expanding the therapeutic options for managing peripheral vascular occlusive disease.