The blue toe syndrome: hemodynamics and therapeutic correlates of outcome

We reviewed the limb and digit hemodynamics of 67 extremities of 48 patients evaluated for blue toe syndrome in our vascular laboratory during 7 years. These patients represented 1.4% of the arterial examinations during this period. Abnormal ankle/arm pressure indices (less than 0.9), signifying proximal arterial obstruction, were present in 31 limbs (47%). Toe/ankle indices were abnormal (less than 0.6) in 57 extremities (85%), indicating pedal or digital artery obstruction. Arteriograms were obtained in 40 of 64 extremities (63%) available for follow-up, which revealed atherosclerotic disease in 90% (aortoiliac 20%, femoropopliteotibial 30%, and combined 40%), aneurysm in 7.5%, and no disease in only one extremity (2.5%). Of 64 extremities followed for 1 to 84 months (mean, 26 months), only 28 (44%) manifested an uncomplicated outcome. Tissue loss was noted in 24 (38%), recurrent digital ischemia occurred in nine (14%), and 14 limbs (22%) required amputation of toe(s) (seven), forefeet (three) or legs (four). Nine patients (20%) died in the follow-up period. Outcomes did not correlate with limb or digit hemodynamics or with therapy (surgical in 31, medical in 11, or none in 22) except that tissue necrosis was more common in patients undergoing operation. The blue toe syndrome deserves recognition as an important sign of potential limb-threatening arterial disease, but the optimal therapy remains to be established.