The Place of Nailfold Capillaroscopy Among Instrumental Methods for Assessment of Some Peripheral Ischaemic Syndromes in Rheumatology.

Micro- and macrovascular pathology is a frequent finding in a number of common rheumatic diseases. Secondary Raynaud's phenomenon (RP) is among the most common symptoms in systemic sclerosis and several other systemic autoimmune diseases including a broad differential diagnosis. It should be also differential from other peripheral vascular syndromes such as embolism, thrombosis, etc., some of which lead to clinical manifestation of the blue toe syndrome. The current review discusses the instrumental methods for vascular assessments. Nailfold capillaroscopy is the only method among the imaging techniques that can be used for morphological assessment of the nutritive capillaries in the nailfold area. Laser-Doppler flowmetry and laser-Doppler imaging are methods for functional assessment of microcirculation, while thermography and plethysmography reflect both blood flow in peripheral arteries and microcirculation. Doppler ultrasound and angiography visualize peripheral arteries. The choice of the appropriate instrumental method is guided by the clinical presentation. The main role of capillaroscopy is to provide differential diagnosis between primary and secondary RP. In rheumatology, capillaroscopic changes in systemic sclerosis have been recently defined as diagnostic. The appearance of abnormal capillaroscopic pattern inherits high positive predictive value for the development of a connective tissue disease that is higher than the predictive value of antinuclear antibodies. In cases of abrupt onset of peripheral ischaemia, clinical signs of critical ischaemia, unilateral or lower limb involvement, Doppler ultrasound and angiography are indicated. The most common causes for such clinical picture that may be referred to rheumatologic consultation are the antiphospholipid syndrome, mimickers of vasculitides such as atherosclerosis with cholesterol emboli, and neoplasms.

Axillo-femoral bypass steal due to subclavian artery stenosis.

Subclavian artery stenosis can cause a flow reversal-so-called steal-not only in the ipsilateral vertebral artery, but also in the internal mammary artery in patients with a history of coronary-artery bypass grafting. Subclavian artery stenosis is also associated with peripheral artery disease elsewhere. We report a novel finding of axillo-femoral bypass steal due to subclavian artery stenosis identified by vascular ultrasonography.

Complete removal of infected abdominal aortic stent-graft with suprarenal fixation.

Stent-graft infections after endovascular aneurysm repair are rare but can have devastating consequences. Open surgery to treat such infections is associated with considerable morbidity and mortality. Removal of the stent-graft is technically challenging, especially when it has a suprarenal fixation. Several in situ reconstructions have been described, with varying results. We report a case in which a Zenith stent-graft became infected after endovascular aneurysm repair to treat an abdominal aortic aneurysm and blue toe syndrome. The endoprosthesis was removed completely, and in situ reconstruction was performed successfully and without complications by using a rifampin-soaked Dacron graft.

Native superficial femoral artery peripheral atherectomy site pseudoaneurysm: a case report.

A 45-year-old woman who presented with blue toe syndrome was treated with atherectomy for a focal plaque located in the superficial femoral artery. She subsequently developed a large pseudoaneurysm at the atherectomy site requiring multiple sequential endovascular procedures in order to maintain in-line blood flow to the foot. Pseudoaneurysm formation at native peripheral artery atherectomy site has not been reported previously. We discuss possible complications of atherectomy and the possible mechanism of pseudoaneurysm formation after atherectomy. We address the importance of understanding risks of these minimally invasive procedures along with planning follow-up duplex and potential bail-out tactics.

Atheroembolic signals detected by Doppler ultrasound scan monitoring in a patient with blue toe syndrome: report of a case.

It is generally accepted that clinical symptoms give the only clue to the presence of atheroemboli in patients with blue toe syndrome (BTS). We report a case of atheroemboli originating from the abdominal aortic aneurysm in which Doppler ultrasound successfully detected atheroembolic signals, which vanished immediately after surgery. To our knowledge, this is the first such case to be documented. When a 67-year-old man was given warfarin after aortocoronay bypass, digital cyanosis suddenly developed, which became worse and was very painful. Angiography and computed tomography scanning revealed an infrarenal aortic aneurysm with mural thrombus. Doppler ultrasound detected atheroemboli as high-intensity transient signals in the bilateral tibioperoneal trunks. After aneurysmectomy and a bifurcated graft replacement, the cyanotic and painful toes improved immediately. Microscopically, cholesterin crystals were seen in the arterioles of the amputated digits. Thus, Doppler ultrasound could be a valuable test to determine the appropriate treatment for patients at risk of atheroembolic BTS.

Doppler ultrasound monitoring for detection of microembolic signals in peripheral arteries.

OBJECTIVE: to use Doppler ultrasound to detect peripheral microemboluation. METHODS: standard Transcranial Doppler equipment was used to peripheral detect peripheral embolic high intensity transient signals (HITSs) in a pig model following injection of microparticles and atheroma, and in 23 patients who underwent open repair of an abdominal aortic aneurysm (AAA), six patients with blue toe syndrome and 10 age matched healthy subjects. RESULTS: the pig study showed increasing signal intensity with particle size. Particles of 100 (n=24), 200 (n=17), and 400 microm (n=31) elicited 14, 25, 33 dB signals, respectively (p<0.05). During AAA surgery, the intensity (median) of HITSs before clamping (n=226) and after declamping (n=1216) were 14, and 20dB, respectively (p<0.001). Quite a few HITSs were detected after surgery. In patients with blue toe syndrome, a total of 63 HITSs could be detected, and the frequency of HITSs (median: 5.72/30min) was significantly higher than that in patients with AAA before surgery (0.065/30min) (p<0.001). CONCLUSIONS: Doppler ultrasound technique may be a clinically useful test to guide the treatment of patients at risk of distal atheroembolic events.

Penetrating ulceration of the infrarenal aorta: case reports of an embolic and an asymptomatic lesion.

Penetrating aortic ulceration is uncommon in the infrarenal aorta. We describe a patient with a penetrating infrarenal aortic ulcer manifesting as blue toe syndrome, and a second patient with a similar lesion identified as an incidental finding. These two patients were treated for penetrating infrarenal aortic ulceration within the past 9 months at two university-affiliated hospitals, a regional Veterans Administration Medical Center, and a County Medical Center. Both lesions demonstrated aneurysm changes with varying degrees of mural thrombus. The lesion filled with fresh thrombus proved labile, with embolization manifesting as blue toe syndrome. We support the aggressive treatment of aneurysmal penetrating aortic ulcer with aortic graft replacement to eliminate the potential for distal embolization and to obviate the risk of rupture and death.

Transesophageal echocardiographic findings in blue toe syndrome exacerbated by anticoagulation.

The role of anticoagulation in the blue toe syndrome is unresolved. We describe the sonographic appearance of atherosclerotic plaques in the thoracic aorta imaged by transesophageal echocardiography in 2 patients with blue toe syndrome who had reembolization while taking therapeutic levels of anticoagulants. The findings of complex atheromas associated with mobile highly echodense linear structures by transesophageal echocardiography may be predictive of reembolization in patients with blue toe syndrome who are taking anticoagulants.

Blue toe syndrome from a "coral reef" aorta.

An endoaortic calcified mass, sometimes referred to as a "coral reef" aorta, is an unusual cause of distal leg microembolization. When discovered it is usually in the suprarenal aorta. We present an unusual case of infrarenal coral reef aorta with symptoms of distal atheroembolism. A review of the literature is also presented.