Acute digital ischemia (Blue finger syndrome)

Specialty: Cardiovascular.

• sharp blue fingers
• acute digital arterial occlusion
• ischemia of small vessels of the hand or foot

Why it occurs

• Cholesterol crystal embolism (atheroembolism) from proximal ulcerated plaques (aorta, iliofemoral arteries)
• In situ thrombosis due to antiphospholipid antibodies or severe hypercoagulability
• Idiopathic arterial spasm or due to exposure to extreme cold
• Embolism of cardiac origin (atrial fibrillation, infective endocarditis, myxoma)
• Secondary Raynaud's phenomenon with fixed microvascular occlusion
• Consumption of cocaine or amphetamines with induction of severe vasospasm

Initial workup

General analysis with complete blood count (search for eosinophilia), erythrocyte sedimentation rate, C-reactive protein, serum creatinine and urinary sediment to rule out concomitant renal involvement; Arterial Doppler ultrasound of the affected extremity and transesophageal echocardiogram to look for the source of embolism (complex aortic plaques, valvular vegetations or atrial thrombi); Computed tomography angiography (CT-Angio) of the aorta and peripheral vessels.

Standard management

• Iloprost — prostacyclin analog indicated to induce vasodilation of microcirculation and suppress platelet aggregation; 0.5 to 2 ng/kg/min daily intravenous infusion over 6 hours for 5 to 10 days
• Acetylsalicylic acid — antiplatelet agent indicated to prevent platelet aggregation on endothelial microfissures; 100 mg per day orally
• Clopidogrel — 75 mg per day orally as alternative or adjuvant therapy
• Alprostadil — prostaglandin E1, indicated if iloprost is not available; 20 to 40 mcg intravenous as a slow infusion
• Atorvastatin (high-potency statin to promote the regression and stabilization of the ulcerated atheromatous plaque that is the source of cholesterol emboli; 80 mg per day orally).