Blue Toe Syndrome Leads to Amputation Despite Source Control
- A 72-year-old woman underwent an emergency below-knee amputation after developing atheroembolic blue toe syndrome, despite undergoing prior endovascular aortic repair and multiple limb salvage procedures.
- The patient initially presented on day 0 with a painful blue discoloration on her left third toe.
- Further evaluation via computed tomography angiography with runoff revealed distal infrarenal aortic soft plaque alongside distal tibial and pedal arterial disease.
A 72-year-old woman underwent an emergency below-knee amputation after developing atheroembolic blue toe syndrome, despite undergoing prior endovascular aortic repair and multiple limb salvage procedures.
Patient Presents with Painful Blue Toe Discoloration
The patient initially presented on day 0 with a painful blue discoloration on her left third toe. Her medical history included peripheral arterial disease, diabetes mellitus, antiphospholipid syndrome, and prior thromboembolic disease. Initial lower extremity arterial duplex ultrasound showed no significant stenosis or arterial occlusion, presenting a diagnostic puzzle because the clinical appearance of ischemia was far more severe than large-vessel imaging suggested.
Further evaluation via computed tomography angiography with runoff revealed distal infrarenal aortic soft plaque alongside distal tibial and pedal arterial disease. Clinicians identified the aortic lesion as the suspected proximal embolic source. Blue toe syndrome typically occurs when plaque or debris travels from sources like the aorta or iliac artery into smaller digital vessels, causing acute ischemia while proximal pulses remain palpable.
Aortic Repair Fails to Stop Gangrene and Infections
The patient underwent endovascular repair of the aorta to achieve proximal source control and prevent further embolization. Despite this intervention, her left third toe progressed to dry gangrene, requiring an initial amputation. Over the following months, her condition deteriorated with nonhealing wounds, worsened distal perfusion, and recurrent infections involving Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus, alongside chronic osteomyelitis.
Medical teams performed multiple limb salvage operations to save the limb. These procedures included angioplasty, further toe amputation, common plantar embolectomy, plantar bypass, transmetatarsal amputation, Achilles tendon lengthening, antibiotic bead placement, and external fixation. Despite these interventions, the foot developed worsening ischemic and infected tissue loss, necessitating an emergency left below-knee amputation.
Pathology Confirms Necrosis and Distal Arterial Disease
Final pathology confirmed gangrenous necrosis, chronic osteomyelitis, calcific atherosclerosis, and tibial vessel occlusions. The outcome demonstrates that treating a proximal embolic source does not guarantee restored distal tissue perfusion when significant distal arterial disease, poor microvascular oxygenation, and severe infection are present. The case illustrates the complex overlap between blue toe syndrome and severe peripheral arterial disease.
Medical literature notes that the clinical course of atheroembolic disease can range from mild local digital ischemia to progressive tissue loss requiring definitive amputation. When distal runoff disease is severe, patients face high risks of nonhealing wounds and limb loss even after successful endovascular or surgical management of proximal lesions.
Final pathology confirmed gangrenous necrosis, chronic osteomyelitis, calcific atherosclerosis, and tibial vessel occlusions in the amputated limb.