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Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg 2021; 79:122-126. [PMID: 34644637 PMCID: PMC8502248 DOI: 10.1016/j.avsg.2021.07.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/17/2021] [Accepted: 07/18/2021] [Indexed: 12/30/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has been widely reported to be associated with increased risk of Venous Thromboembolism, both deep vein thrombosis (DVT) and pulmonary embolism. A rare and extreme manifestation of DVT is Phlegmasia cerulea dolens, characterized by poor tissue perfusion due to marked limb swelling which can progress to limb and life-threatening venous gangrene. We report the case of a 53-year-old man with severe SARS-CoV2 pneumonia who developed acute iliofemoral DVT leading to acute limb ischemia due to Phlegmasia cerulea dolens. The patient underwent successful emergent fasciotomy and mechanical thrombectomy with removal of extensive thrombus burden and restoration of normal venous circulation. Our case highlights the importance of clinical vigilance and early implementation of therapeutic interventions to avoid adverse outcomes in patients who develop SARS-CoV2 induced Venous Thromboembolism complications.
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Affiliation(s)
- Josue R Gutierrez
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | | | - Edvard Skripochnik
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | - Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY.
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Abootalebi A, Salemi M, Heidari F, Azimi Meibody A. Phlegmasia Cerulea Dolens: A Rare Case Report. Adv Biomed Res 2020; 9:31. [PMID: 33072643 PMCID: PMC7532826 DOI: 10.4103/abr.abr_3_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/12/2020] [Accepted: 04/07/2020] [Indexed: 11/08/2022] Open
Abstract
Phlegmasia cerulea dolens is a severe form of deep venous thrombosis (DVT) characterized by severe venous outflow obstruction, marked limb swelling, pain, bluish discoloration, and even venous gangrene if the condition is untreated. In our case, 75-year-old woman, with general abdominal pain, which increases with eating and anorexia and 5 days of coldness and swelling of the left leg, was accepted. The patient had a history of Type II diabetes, ischemic heart disease, congestive heart failure, hyperlipidemic (HLP), hypertension, metastatic ovarian cancer, and previous DVT. She has undergone chemotherapy for the past 3 weeks due to ovarian cancers. Anticoagulation with intravenous administration of heparin and fluid resuscitation started immediately. The evidence of color Doppler sonography approved acute DVT in common femoral vein extending to the left external iliac. The patient did not consent for continuing the procedure in the hospital and succumbed to her illness on the 7th day after discharge.
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Affiliation(s)
- Alireza Abootalebi
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Salemi
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farhad Heidari
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azita Azimi Meibody
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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3
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Abstract
Phlegmasia cerulea dolens (PCD) is a rare presenting condition that carries a high mortality and morbidity risk. It is a cannot miss diagnosis with potentially deadly sequelae, and we highlight the importance of a thorough physical examination and initiation of empiric treatment to help prevent such.
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Affiliation(s)
- Davin Barnett
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
| | - John Casey
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
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Mouawad NJ. Effective single-session percutaneous nonpharmacologic mechanical thrombectomy for phlegmasia cerulea dolens. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:212-215. [PMID: 32322779 PMCID: PMC7162958 DOI: 10.1016/j.jvscit.2020.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/08/2020] [Indexed: 11/19/2022]
Abstract
Phlegmasia cerulea dolens can be a potentially devastating complication of severe deep venous thrombosis leading to limb ischemia and tissue necrosis. This report describes a patient presenting with phlegmasia cerulea dolens of the right lower extremity. Because of the urgent nature of the condition, percutaneous nonpharmacologic mechanical thrombectomy in a single session was pursued. Extensive thrombus burden was removed from the patient, and vessel patency was restored after balloon venoplasty. The patient's symptoms rapidly resolved, and the targeted vessels remain patent at 3-month follow-up.
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Affiliation(s)
- Nicolas J. Mouawad
- Correspondence: Nicolas J. Mouawad, MD, MPH, MBA, FSVS, FRCS, FACS, RPVI, McLaren Bay Region, 1900 Columbus Ave, 4th Fl, South Tower, Bay City, MI 48708
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Núñez-Rojas G, Lozada-Martinez ID, Bolaño-Romero MP, Ramírez-Barakat E. Isquemia arterial aguda de las extremidades: ¿cómo abordarla? REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
La isquemia arterial aguda de las extremidades se define como la interrupción abrupta del flujo sanguíneo a determinado tejido, lo cual afecta la integridad, la viabilidad de la extremidad, o ambas. Las causas son múltiples y pueden resumirse en dos procesos fisiopatológicos, trombóticos o embólicos, con lo que se puede establecer el pronóstico y el tratamiento según su causa.
El cuadro sindrómico es variable, y típicamente, se identifica con las cinco “P” de Pratt (pain, pallor, pulselessness, paralysis and paresthesia); se cuenta con múltiples ayudas diagnósticas, pero la arteriografía sigue siendo el método estándar para el diagnóstico.
Con el advenimiento de los avances tecnológicos y los procedimientos vasculares, el salvamento de las extremidades ha venido en aumento y ha disminuido la extensión de las amputaciones, lo cual conlleva una mayor tasa de rehabilitación y de reincorporación a la vida social.
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6
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Phlegmasia Cerulea Dolens in a Patient with Breast Cancer and Inferior Vena Cava Hypoplasia. Case Rep Vasc Med 2020; 2020:2176848. [PMID: 32181047 PMCID: PMC7066424 DOI: 10.1155/2020/2176848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/24/2020] [Indexed: 12/05/2022] Open
Abstract
Background No clear guidelines exist for the management of phlegmasia cerulea dolens. This case report shows how a hybrid approach might be successful. It also shows how rare pathologies can combine to create a life- and limb-threatening condition. Case Presentation. A 75-year-old man, known for nephrotic syndrome currently under investigation, presented to the emergency department with a 24-hour history of left leg swelling followed by intense pain. The left lower limb showed a phlegmasia cerulean dolens. Renal function, coagulation profile, and inflammatory parameters were normal; D-Dimers 5,6 mg/L. The CT scan showed juxtarenal thrombosis of the hypoplastic IVC, involving both renal veins, reaching the left iliac-femoral-popliteal axis, with collateralization to the pelvic and mesenteric veins, associated with bilateral segmental pulmonary embolisms. A suspected left breast nodule was also found. Intravenous heparin was immediately administered, and urgent hybrid procedure with surgical thrombectomy and venous angiography and thromboaspiration, liberating the iliolumbar collaterals, was performed. A lateral leg fasciotomy was mandatory due to the phlegmasia cerulea. Postoperative Doppler US showed a good venous compressibility of the left leg. Thrombophilia screening was negative. The breast nodule was biopsied showing an invasive ductal carcinoma. The patient was discharged with oral rivaroxaban and indication for left mastectomy and oncological therapy with aromatase inhibitors. Conclusion This case highlights the dramatic consequence of different risk factors for venous thromboembolism as cancer and nephrotic syndrome in a patient with hypoplasia of the inferior cava vein. Venous thromboaspiration has been used in order to timely recanalize important collaterals. Phlegmasia cerulea dolens was resolved after the procedure and lateral calf fasciotomy. Further evidence is needed to clearly define the role of venous thromboaspiration in the treatment of complex proximal deep venous thrombosis of the lower extremity.
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Kommalapati A, Kallam A, Krishnamurthy J, Tella SH, Koppala J, Tandra PK. Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia Leading to Gangrene. Cureus 2018; 10:e2853. [PMID: 30148006 PMCID: PMC6104908 DOI: 10.7759/cureus.2853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023] Open
Abstract
We present a case of a dialysis-dependent end-stage renal disease patient who originally presented with sepsis and later developed heparin-induced thrombocytopenia-related upper extremity deep venous thrombosis that rapidly progressed to phlegmasia. Argatroban, a direct thrombin inhibitor, was initiated without delay. Argatroban restored the venous patency completely but did not reverse his two gangrenous fingers. The patient finally underwent digital amputation. The management of this uncommon, but life-threatening, situation of upper limb phlegmasia cerulea dolens secondary to heparin-induced thrombocytopenia leading to gangrene is discussed in this case report.
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Affiliation(s)
| | - Avyakta Kallam
- Hematology and Oncology, University of Nebrask, Omaha, USA
| | | | - Sri H Tella
- Internal Medicine, University of South Carolina, Columbia, USA
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Gaines M, Grant M, Robinson S, Stevenson H. Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia: A Case Study. J Orthop Case Rep 2018; 7:55-58. [PMID: 29600212 PMCID: PMC5868885 DOI: 10.13107/jocr.2250-0685.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Phlegmasia cerulea dolens (PCD) is a rare pathology with a very high morbidity and mortality rate, which usually occurs in the lower limb. There is very little literature available to aid management. Case Report: We present a case of upper limb PCD in a 67-year-old female secondary to heparin-induced thrombocytopenia caused by warfarin bridging. She presented to the orthopedic team with upper limb compartment syndrome from a bleed around a peripherally inserted central catheter, for which she was urgently taken to the theater for fasciotomies. Postoperatively, the patient’s platelets dropped and the upper limb pain and swelling continued; after conservative management and anticoagulation failed the patient had an upper limb amputation of her right arm. Conclusion: With limited guidelines and management options restricted by the large fasciotomy wounds, we believe amputation was the patients’ best option.
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Affiliation(s)
- Matthew Gaines
- Department of Trauma and Orthopaedics, Bachelor of Medicine and Bachelor of Surgery, Aintree University Liverpool, Liverpool, England, United Kingdom
| | - Mike Grant
- Department of Trauma and Orthopaedics, Bachelor of Medicine and Bachelor of Surgery, Aintree University Liverpool, Liverpool, England, United Kingdom
| | - Simon Robinson
- Department of Trauma and Orthopaedics, Bachelor of Medicine and Bachelor of Surgery, Aintree University Liverpool, Liverpool, England, United Kingdom
| | - Helene Stevenson
- Department of Trauma and Orthopaedics, Bachelor of Medicine and Bachelor of Surgery, Aintree University Liverpool, Liverpool, England, United Kingdom
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Abdul W, Hickey B, Wilson C. Lower extremity compartment syndrome in the setting of iliofemoral deep vein thrombosis, phlegmasia cerulea dolens and factor VII deficiency. BMJ Case Rep 2016; 2016:bcr2016215078. [PMID: 27113791 PMCID: PMC4854131 DOI: 10.1136/bcr-2016-215078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/03/2022] Open
Abstract
Acute compartment syndrome requires urgent fasciotomies to prevent irreversible muscle damage. We present a case of massive iliofemoral deep vein thrombosis (DVT) presenting as acute compartment syndrome. A healthy 21-year-old man presented with a 2-day history of worsening left leg pain with swelling and bluish discolouration. Clinical diagnosis of compartment syndrome secondary to phlegmasia cerulea dolens (PCD) was made and he underwent emergency fasciotomies. Postoperative venous duplex confirmed a massive iliofemoral DVT and intravenous heparin was started. Following skin grafting, the patient made a good recovery. Massive iliofemoral DVT is an uncommon cause of compartment syndrome and has been reported in lower limbs, secondary to PCD. Failure to treat early carries a high degree of morbidity, with amputation rates up to 50% and mortality rates between 25% and 40%. It is important to recognise compartment syndrome as an acute presentation of PCD. Urgent fasciotomies can prevent limb amputation and mortality.
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Affiliation(s)
- Wahid Abdul
- Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
| | - Ben Hickey
- Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
| | - Chris Wilson
- Department of Trauma and Orthopaedics, Cardiff and Vale University Health Board, Cardiff, UK
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10
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Tran J, Rafique Z. Phlegmasia Cerulea Dolens in the Pediatric Population: A Life-threatening Condition. J Emerg Med 2015; 49:e111-4. [PMID: 26242924 DOI: 10.1016/j.jemermed.2015.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 05/22/2015] [Accepted: 05/29/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Phlegmasia cerulea dolens is a rare complication of deep venous thromboembolism that can have life-threatening consequences. It is more commonly reported in the adult population, and rarely in the pediatric population, especially in a healthy child. CASE REPORT We report a case of a healthy 7-year-old girl who presented with right leg pain and fever, found to have a thrombus involving her inferior vena cava and right lower extremity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of early recognition and a multimodal approach to treatment of phlegmasia cerulea dolens.
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Affiliation(s)
- John Tran
- Department of Emergency Medicine, Baylor College of Medicine, Emergency Center, Ben Taub Hospital, Houston, Texas
| | - Zubaid Rafique
- Department of Emergency Medicine, Baylor College of Medicine, Emergency Center, Ben Taub Hospital, Houston, Texas
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11
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Bravo Molina A, Ros Vidal R, Ros Díe E. Flegmasia cerúlea dolens como presentación de aneurisma ilíaco. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Hu H, Cai Y, Wang C, Yang C, Duan Z, Zhang J, Xin S. Successful treatment of posttraumatic phlegmasia cerulea dolens by reconstructing the external iliac vein: a case report. J Med Case Rep 2014; 8:149. [PMID: 24885801 PMCID: PMC4048049 DOI: 10.1186/1752-1947-8-149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 03/10/2014] [Indexed: 11/12/2022] Open
Abstract
Introduction Phlegmasia cerulea dolens is a rare condition caused by complete venous occlusion leading to impaired arterial flow. To prevent progression to limb gangrene, prompt diagnosis and treatment initiation are paramount. Here we report a rare case of posttraumatic phlegmasia cerulea dolens after ligation of the iliac vein to save the patient's life, with successful treatment by reconstructing the external iliac vein. This is the first report of posttraumatic phlegmasia cerulea dolens induced by iliac vein ligation. Case presentation A 49-year-old Chinese man was admitted to a local hospital for severe knife trauma with massive intraperitoneal bleeding. During exploratory laparotomy, he was diagnosed with traumatic rupture of his left external iliac vein without injury to the iliac artery. The proximal and distal parts of his injured external iliac vein were ligated to control the bleeding and rescue him, but his left leg quickly became severe swollen, cyanotic and pulseless. He was diagnosed with posttraumatic phlegmasia cerulea dolens after being transferred to our university hospital. After a retrievable filter was placed in his inferior vena cava via his right femoral vein, he underwent reopening of his abdomen followed by successful surgical reconstruction of his left iliac vein. He was treated with anticoagulation therapy postoperatively and his signs and symptoms improved markedly. He was discharged in a stable condition, with nearly full resolution of symptoms, 35 days after the operation. Conclusions Our case demonstrates that ligation of an injured iliac vein may induce phlegmasia cerulea dolens in a posttraumatic scenario; prompt reconstruction of the iliac vein to restore the venous drainage is an effective treatment for phlegmasia cerulea dolens with impending gangrene.
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Affiliation(s)
- Haidi Hu
- Division of Vascular and Thyroid Surgery, Department of Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China.
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Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg 2011; 45:5-14. [PMID: 21193462 DOI: 10.1177/1538574410388309] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Phlegmasia cerulea dolens (PCD) is a fulminant condition of acute massive venous thrombosis that may result in major amputation or death unless treated in an early phase. Guidelines for treatment are still not clearly documented. As a consequence, physicians might have limited knowledge of this potential life-threatening condition and its clinical course. Therefore, the purpose of this review was to analyze and summarize clinical manifestations and proposed diagnostic approach, factors that affect the outcome of PCD, and the evolution of management and therapeutic options. Underlying malignancy, pulmonary embolism, and PCD severity are the vital factors that predict the outcome of PCD. In the last decades, treatment options have remained largely unchanged. Published evidence shows that advances in minimally invasive techniques have not yet resulted in outcome improvements compared with traditional surgical thrombectomy. Treatment seems to depend on grading the severity of this condition and experience of the surgeon.
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Affiliation(s)
- Khamin Chinsakchai
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Mesfin A, Lum YW, Nayfeh T, Mears SC. Compartment syndrome in patients with massive venous thrombosis after inferior vena cava filter placement. Orthopedics 2011; 34:229. [PMID: 21410121 DOI: 10.3928/01477447-20110124-23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Massive venous thrombosis, which can occur acutely after inferior vena cava filter placement, has 2 forms: phlegmasia cerulea dolens and phlegmasia alba dolens. In phlegmasia cerulea dolens, complete occlusion of venous outflow occurs. In the milder phlegmasia alba dolens version, collateral venous flow out of the limb remains despite the venous thrombosis. This article presents, to our knowledge, the first 2 cases of massive venous thrombosis (1 phlegmasia cerulea dolens, 1 phlegmasia alba dolens) below inferior vena cava filters occurring after the acute period. Phlegmasia cerulea dolens and phlegmasia alba dolens can present as compartment syndrome. Prompt fasciotomies were performed, but the underlying massive venous thrombosis was not addressed surgically. Phlegmasia cerulea dolens and phlegmasia alba dolens have high morbidity and mortality. The patient with phlegmasia alba dolens required leg and thigh fasciotomies and eventually required an above-knee amputation. The patient with phlegmasia cerulea dolens developed compartment syndrome in the left leg, right leg, and right thigh. Although he underwent decompression of all of these compartments, he died from multiple organ failure. A multidisciplinary approach with the vascular service and the intensivists is required in the treatment of patients with massive venous thrombosis. Treatment goals include preventing additional propagation of the thrombus via anticoagulation, with strong consideration for catheter-directed thrombolysis or thrombectomy and fasciotomies for compartment syndrome. The orthopedic surgeon should keep phlegmasia cerulea dolens and phlegmasia alba dolens in the differential for compartment syndrome, especially in patients who have had a history of acute or chronic inferior vena cava filter placement.
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Affiliation(s)
- Addisu Mesfin
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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15
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Alonso E, Krypciak S, Taillandier E, Tahmasebi F, Paillaud E. [A big purple leg]. Rev Med Interne 2010; 32:116-7. [PMID: 20541854 DOI: 10.1016/j.revmed.2010.03.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 03/06/2010] [Indexed: 11/19/2022]
Affiliation(s)
- E Alonso
- Département de médecine interne et gériatrie, hôpital Chenevier-Mondor, 40, rue de Mesly, 94010 Créteil cedex, France.
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16
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Roettges PS, Murray PM, Hill D. Hand gangrene following unsuccessful cannulation of the internal jugular vein: a case report and literature review. Hand (N Y) 2010; 5:206-9. [PMID: 19756870 PMCID: PMC2880673 DOI: 10.1007/s11552-009-9222-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 08/19/2009] [Indexed: 11/25/2022]
Abstract
Hand gangrene following vascular cannula placement is uncommon and is usually the result of thrombotic occlusion of an artery. We describe a case of hand gangrene resulting in wrist disarticulation, following multiple unsuccessful attempts at internal jugular vein cannulation in a critically ill patient.
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Affiliation(s)
- Paul S. Roettges
- Neuroscience Research, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Peter M. Murray
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - David Hill
- Department of Family Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
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17
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Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol 2009; 60:1-20; quiz 21-2. [DOI: 10.1016/j.jaad.2008.09.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 08/26/2008] [Accepted: 09/03/2008] [Indexed: 01/19/2023]
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18
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Bilateral Phlegmasia Dolens Associated With Trousseau's Syndrome: A Case Report. Arch Phys Med Rehabil 2008; 89:1187-90. [DOI: 10.1016/j.apmr.2007.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2007] [Revised: 10/16/2007] [Accepted: 10/17/2007] [Indexed: 11/19/2022]
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19
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Wetz RC, Stroup JS, Roberts ML. Phlegmasia Cerulea Dolens in a Patient with Heparin-Induced Thrombocytopenia. J Pharm Technol 2008. [DOI: 10.1177/875512250802400306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To report a case of the venous obstructive condition known as phlegmasia cerulea dolens (PCD) in the presence of heparin-induced thrombocytopenia (HIT). Case Summary: A 50-year-old white female presented to the emergency department with a 2-day history of a bluish discoloration of her toes and hands accompanied by chest pain and shortness of breath. The evident edema, tenderness on palpation, and cyanosis of the extremities were suggestive of PCD. She had been hospitalized approximately one month previously due to a fibular fracture and again within the past 2 weeks for intractable abdominal pain and nausea. During her current hospital stay, she was diagnosed with multiple venous thromboembolisms (VTEs); at the time of admission, an unfractionated heparin (UFH) drip was initiated to treat her VTEs. Due to a decreased platelet count on admission, a platelet factor 4 (PF4) antibody assay was performed and found to be positive. After discontinuation of UFH, her platelet count slowly returned to normal range. Discussion: The pathogenesis of HIT is due to formation of antibodies against the complex of heparin and PF4. HIT is characterized by a reduction in the platelet count approximately 4–14 days after the initiation of heparin therapy plus a paradoxical prothrombotic state. The typical diagnostic clues are a drop in platelet count of 50% from baseline with the initiation of heparin and a positive assay for heparin-PF4-immunoglobulin G. This condition may result in PCD, which presents as the triad of pain, edema, and cyanosis. This condition often results in venous or arterial thrombus formation. The treatment for PCD includes immediate discontinuation of heparin products and anticoagulation with a direct thrombin inhibitor. Conclusions: Thromboembolic complications such as PCD are often observed as a presenting feature of HIT. To avoid these potentially limb- and life-threatening complications, clinicians must be vigilant in their monitoring of platelets and clinical signs and symptoms of HIT while patients are on heparin therapy.
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Affiliation(s)
- R Colin Wetz
- R COLIN WETZ DO, Internal Medicine Resident, Oklahoma State University Medical Center, Tulsa, OK
| | - Jeffrey S Stroup
- JEFFREY S STROUP PharmD BCPS, Assistant Professor of Medicine, Oklahoma State University Center for Health Sciences, Tulsa
| | - Montgomery L Roberts
- MONTGOMERY L ROBERTS DO, Assistant Professor of Medicine, Oklahoma State University Center for Health Sciences
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Phlegmasia cerulea dolens as a complication of a severe form of acute hemorrhagic-necrotizing pancreatitis. Blood Coagul Fibrinolysis 2008; 19:98-100. [PMID: 18180625 DOI: 10.1097/mbc.0b013e3282f38c38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Phlegmasia cerulea dolens is an extreme form of deep venous thrombosis with a proximal localization of the blockage, most frequently in the ileofemoral area. Symptoms are graded as follows: swelling of the entire extremity, pain, and cyanosis. This form of the disease is rare, occurring most frequently in the terminal stage of malignancies. Diagnosis of phlegmasia usually causes no problems because the proper diagnosis is usually revealed during clinical examination and confirmed by imaging techniques. The authors present a case report of phlegmasia cerulean dolens and discuss the options for treatment.
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