A 61-year-old man presented to the emergency department (ED) complaining of right great toe pain and worsening blue discoloration for 8 days. The patient was afebrile, and the remaining vital signs were normal. Physical examination was notable for symmetric and palpable posterior tibial and dorsalis pedis pulses with a mottled and cyanotic right great toe (Fig. 1). Ankle brachial pressure index on the right measured 1.1, and on the left was 1.2 (both normal range). Toe pressures were 0 mmHg on the right great toe, 104 mmHg on the right second toe, and 114 mmHg on the left great toe. An EKG displayed a sinus rhythm, and a CT angiography of the abdomen and pelvis with three-vessel runoff revealed a fusiform, infrarenal, abdominal aortic aneurysm measuring 5.2 cm 9 5.5 cm 9 8.3 cm, with a mural thrombus that extended into the right common iliac artery. The patient's toe pain was not relieved with intravenous narcotics; therefore, a digital block with 1 % lidocaine was performed, which temporarily alleviated his pain completely.

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