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Lebeau J, Leung J, Bernard L, Zeng X, Levin G. Phlegmasia cerulea dolens - A rare presentation of ovarian malignancy. Eur J Obstet Gynecol Reprod Biol 2024; 298:212-213. [PMID: 38845261 DOI: 10.1016/j.ejogrb.2024.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 05/24/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Jonathan Lebeau
- Faculty of Medicine and Health Sciences, McGill University, QC, Canada.
| | - Jasmine Leung
- Faculty of Medicine and Health Sciences, McGill University, QC, Canada
| | - Laurence Bernard
- Department of Gynecologic Oncology, Royal Victoria Hospital, McGill University, QC, Canada
| | - Xing Zeng
- Department of Gynecologic Oncology, Royal Victoria Hospital, McGill University, QC, Canada
| | - Gabriel Levin
- Department of Gynecologic Oncology, Jewish General Hospital, McGill University, QC, Canada
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2
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Kawatani Y, Saitoh H, Hori T. Phlegmasia cerulea dolens after endovenous cyanoacrylate closure of incompetent small saphenous vein. J Surg Case Rep 2024; 2024:rjae363. [PMID: 38817790 PMCID: PMC11137603 DOI: 10.1093/jscr/rjae363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024] Open
Abstract
A previously healthy 70-year-old woman underwent cyanoacrylate closure of an incompetent left small saphenous vein. Six days later, grade 2 treatment-induced thrombosis occurred at the sapheno-popliteal junction. Three days later, the patient presented with pale, cold pain in the left lower extremity. Diffuse thrombosis of the left lower extremity involved the small and great saphenous and deep veins. The patient was admitted and immediately administered heparin with anticoagulant factors, with symptoms began resolving 1 d later. The superficial vein thrombi were resolved. Although a deep venous thrombus remained, symptoms disappeared, and the patient was discharged.
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Affiliation(s)
- Yohei Kawatani
- Cardiovascular Surgery, Kamagya-General Hospital, 929-6, Hatsutomi, Kamagaha-Shi, Chiba-Ken 273-0121, Japan
| | - Hirofumi Saitoh
- Internal Medicine, Kamagya-General Hospital, 929-6, Hatsutomi, Kamagaha-Shi, Chiba-Ken 273-0121, Japan
| | - Takaki Hori
- Cardiovascular Surgery, Kamagya-General Hospital, 929-6, Hatsutomi, Kamagaha-Shi, Chiba-Ken 273-0121, Japan
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Bissacco D, Mandigers TJ, Romagnoli S, Aprea T, Lomazzi C, D'Alessio I, Ascenti V, Ierardi AM, Domanin M, Tolva VS, Carrafiello G, Trimarchi S. Acute venous problems: Integrating medical, surgical, and interventional treatments. Semin Vasc Surg 2023; 36:307-318. [PMID: 37330243 DOI: 10.1053/j.semvascsurg.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.
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Affiliation(s)
- Daniele Bissacco
- Department of Clinical and Community Sciences, University of Milan, Via Sforza 35, 20122, Milan, Italy.
| | - Tim J Mandigers
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Romagnoli
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziana Aprea
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Lomazzi
- Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilenia D'Alessio
- Vascular Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Velio Ascenti
- Postgraduate School of Radiology, University of Milan, Milan, Italy
| | - Anna Maria Ierardi
- Radiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Domanin
- Department of Clinical and Community Sciences, University of Milan, Via Sforza 35, 20122, Milan, Italy; Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Gianpaolo Carrafiello
- Radiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical and Community Sciences, University of Milan, Via Sforza 35, 20122, Milan, Italy; Vascular Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
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Vedantham S, Desai KR, Weinberg I, Marston W, Winokur R, Patel S, Kolli KP, Azene E, Nelson K. Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis. J Vasc Interv Radiol 2023; 34:284-299.e7. [PMID: 36375763 DOI: 10.1016/j.jvir.2022.10.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To establish the updated position of the Society of Interventional Radiology (SIR) on the endovascular management of acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS A multidisciplinary writing group with expertise in treating venous diseases was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements. RESULTS A total of 84 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified and included in the review. The expert writing group developed 17 recommendations that pertain to the care of patients with acute iliofemoral DVT with the use of endovascular venous interventions. CONCLUSIONS SIR considers endovascular thrombus removal to be an acceptable treatment option in selected patients with acute iliofemoral DVT. Careful individualized risk assessment, high-quality general DVT care, and close monitoring during and after procedures should be provided.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ido Weinberg
- Cardiology Division, Vascular Medicine Section, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - William Marston
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Ronald Winokur
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Sheena Patel
- Society of Interventional Radiology, Fairfax, Virginia
| | - Kanti Pallav Kolli
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Ezana Azene
- Gundersen Health System, La Crosse, Wisconsin
| | - Kari Nelson
- Department of Radiology, Orange Coast Medical Center, Fountain Valley, California
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5
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Revascularization of acute inferior vena cava thrombosis and atresia in an adolescent. J Vasc Surg Cases Innov Tech 2022; 8:331-334. [PMID: 35812128 PMCID: PMC9263748 DOI: 10.1016/j.jvscit.2022.04.006] [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: 12/21/2021] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Inferior vena cava (IVC) anomalies will remain silent until collateralized venous drainage has been lost. The initial signs can be subtle, including back pain, and are often missed initially until progressive changes toward motor weakness, phlegmasia cerulea dolens, and/or renal impairment have occurred. We have presented a case of acute occlusion of an atretic IVC and infrarenal collateral drainage in an adolescent patient, who had been treated with successful thrombolysis, thrombectomy, and endovascular revascularization for IVC stenting and reconstruction.
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Hendley SA, Dimov A, Bhargava A, Snoddy E, Mansour D, Afifi RO, Wool GD, Zha Y, Sammet S, Lu ZF, Ahmed O, Paul JD, Bader KB. Assessment of histological characteristics, imaging markers, and rt-PA susceptibility of ex vivo venous thrombi. Sci Rep 2021; 11:22805. [PMID: 34815441 PMCID: PMC8610976 DOI: 10.1038/s41598-021-02030-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/08/2021] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism is a significant source of morbidity and mortality worldwide. Catheter-directed thrombolytics is the primary treatment used to relieve critical obstructions, though its efficacy varies based on the thrombus composition. Non-responsive portions of the specimen often remain in situ, which prohibits mechanistic investigation of lytic resistance or the development of diagnostic indicators for treatment outcomes. In this study, thrombus samples extracted from venous thromboembolism patients were analyzed ex vivo to determine their histological properties, susceptibility to lytic therapy, and imaging characteristics. A wide range of thrombus morphologies were observed, with a dependence on age and etymology of the specimen. Fibrinolytic inhibitors including PAI-1, alpha 2-antiplasmin, and TAFI were present in samples, which may contribute to the response venous thrombi to catheter-directed thrombolytics. Finally, a weak but significant correlation was observed between the response of the sample to lytic drug and its magnetic microstructure assessed with a quantitative MRI sequence. These findings highlight the myriad of changes in venous thrombi that may promote lytic resistance, and imaging metrics that correlate with treatment outcomes.
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Affiliation(s)
- Samuel A Hendley
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA
| | - Alexey Dimov
- Department of Radiology, Weill Cornell Medicine, New York, NY, 10021, USA
| | - Aarushi Bhargava
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Erin Snoddy
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Daniel Mansour
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, University of Texas at Houston, Houston, TX, 77030, USA
| | - Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, IL, 60637, USA
| | - Yuanyuan Zha
- The Human Immunological Monitoring Facility, University of Chicago, Chicago, IL, 60637, USA
| | - Steffen Sammet
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Zheng Feng Lu
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Osman Ahmed
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA
| | - Jonathan D Paul
- Department of Medicine, University of Chicago, Chicago, IL, 60637, USA
| | - Kenneth B Bader
- Committee on Medical Physics, University of Chicago, Chicago, IL, 60637, USA.
- Department of Radiology, University of Chicago, Chicago, IL, 60637, USA.
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Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, Ten Cate-Hoek AJ, Elalamy I, Enzmann FK, Geroulakos G, Gottsäter A, Hunt BJ, Mansilha A, Nicolaides AN, Sandset PM, Stansby G, Esvs Guidelines Committee, de Borst GJ, Bastos Gonçalves F, Chakfé N, Hinchliffe R, Kolh P, Koncar I, Lindholt JS, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, De Maeseneer MG, Comerota AJ, Gloviczki P, Kruip MJHA, Monreal M, Prandoni P, Vega de Ceniga M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2020; 61:9-82. [PMID: 33334670 DOI: 10.1016/j.ejvs.2020.09.023] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Butterworth JA, Huynh TT, Lewis VO, Chang EI. Phlegmasia cerulea dolens following internal hemipelvectomy: Case report and literature review. Injury 2020; 51 Suppl 4:S68-S70. [PMID: 32093946 DOI: 10.1016/j.injury.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/08/2020] [Indexed: 02/02/2023]
Abstract
Phlegmasia cerulea dolens (PCD) results from near complete venous thrombosis and occlusion in an extremity resulting in pain, cyanosis, and edema and potentially death. While PCD can result from a variety of mechanisms including trauma, iatrogenic instrumentation, the majority of cases occur in the setting of malignancy. PCD is often managed medically with anticoagulation. However, in certain circumstances, surgical intervention may be warranted. Here, we present a unique case of phlegmasia cerulea dolens occurring following an internal hemipelvectomy requiring emergent surgical intervention to salvage life and limb. A review of the literature regarding diagnosis and treatment is also presented.
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Affiliation(s)
| | - Tam T Huynh
- Department of Vascular Thoracic Surgery, The University of Texas, MD Anderson Cancer Center, USA
| | - Valerae O Lewis
- Department of Orthopedic Surgery, The University of Texas, MD Anderson Cancer Center, USA
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, The University of Texas, MD Anderson Cancer Center, USA.
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Lee JK, Kim KY, Byun SJ. Safety and Efficacy of Aspiration Thrombectomy or Pharmacomechanical Thrombectomy after Catheter-Directed Thrombolysis for the Treatment of Acute Iliofemoral Deep Vein Thrombosis. Vasc Specialist Int 2020; 36:144-150. [PMID: 32990252 PMCID: PMC7531297 DOI: 10.5758/vsi.200041] [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: 06/15/2020] [Revised: 07/21/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of additional aspiration thrombectomy (AT) or pharmacomechanical thrombectomy (PMT) after catheter-directed thrombolysis (CDT) for the treatment of acute iliofemoral deep vein thrombosis (AIFDVT). MATERIALS AND METHODS Between May 2017 and December 2018, 40 patients with AIFDVT were enrolled. Twenty underwent AT after CDT (CDTAT), while the remaining 20 underwent PMT using an AngioJetTM device after CDT (CDTPMT). Thrombus clearance was assessed using computed tomography venography at 1 week after the procedure, as follows: grade I, ≤50%; grade II, 51% to 75%; grade III, >75%. Grade III was considered a successful outcome. Treatment outcomes (thrombus clearance, thrombolytic therapy duration, urokinase dose, major complications, residual filter thrombosis, and Villalta score) were compared between the groups. RESULTS Successful thrombus clearance was achieved in 95% of the patients in both groups. Significant decreases in the thrombolytic therapy duration (P=0.018) and urokinase dose (P=0.014) were noted in the CDTPMT group. Major complications were not noted in both groups. Residual filter thrombi >10 mm were found in 6 filters in the CDTAT group and in 1 filter in the CDTPMT group (P=0.038). The Villalta scores at 6 months were 1.47±1.24 and 1.12±0.92 in the CDTAT and CDTPMT groups, respectively (P=0.372). CONCLUSION Both methods may be safe and effective management options for patients with AIFDVT. CDTPMT can reduce urokinase dosage, time and remained filter thrombus compared to CDTAT. Studies conducted in the future should compare the effects of overnight CDT followed by PMT with those of single-session PMT on patients with AIFDVT.
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Affiliation(s)
- Joong Kwon Lee
- Division of Vascular Surgery, Department of Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Kyung Yun Kim
- Division of Vascular Surgery, Department of Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Seung Jae Byun
- Division of Vascular Surgery, Department of Surgery, Wonkwang University Hospital, Iksan, Korea
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Abstract
OBJECTIVE The purpose of this study was to assess the clinical features of phlegmasia cerulea dolens and present the treatment outcomes with rheolytic thrombectomy device. METHODS From January 2014 and March 2019, 329 patients were diagnosed and hospitalized for acute iliofemoral deep vein thrombosis, and among those patients, seven patients diagnosed with lower extremity phlegmasia cerulea dolens were consecutively enrolled. Diagnosis of phlegmasia cerulea dolens was initially made on clinical findings followed by imaging with Doppler ultrasound. The rheolytic thrombectomy device was used in all patients with a combination of catheter-directed thrombolysis as an adjunctive therapy to facilitate more rapid thrombus clearance except for one patient who had a contraindication to the use of tissue plasminogen activator. RESULTS Seven patients (four men, three women; median age, 63 years, range 52-68 years) were included. One patient had a relative contradiction to thrombolysis due to history of coronary artery bypass graft surgery; all other patients underwent pharmaco-mechanical thrombectomy with power pulse mode. The upper limit of 480 s was completed in all patients, and this time was not exceeded to prevent hemolysis-related complications. Six Fr catheters were used in four (57.1%) patients, and 8 Fr catheters were used in three patients (42.9%). Mean thrombolytic infusion duration was 28 ± 6.2 h for patients who received tissue plasminogen activator. After catheter-directed thrombolysis, total radiological success was achieved in two patients, and partial radiologic success was achieved in five patients; however, in all seven patients, clinical success was achieved. The mean duration for complete regression of cyanosis was 18.9 ± 8.1 h. Although no patients required blood replacement, mean decreases in hemoglobin and hematocrit were 2.7 ± 1.37 g/dl and 6.42 ± 4.47%, respectively. Acute kidney injury developed in three patients (42.9%). One patient required continuous renal replacement therapy. No cardiac complication was observed. One (14.3%) patient died of ventilator-related pneumonia on postprocedural day 10. The median duration of intensive care unit stay and hospital stay were 72 h (min-max: 24-264 h) and six days (min-max: 5-33 days), respectively. CONCLUSION Rheolytic thrombectomy was less invasive and effective strategy for early stage phlegmasia cerulea dolens at creating rapid thrombus clearance to establish clinical success and facilitate more conservative management with catheter-directed thrombolysis.
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Affiliation(s)
- Onur Saydam
- Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Deniz Serefli
- Department of Cardiovascular Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
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Kou CTJ, Batzlaff C, Bezzant ML, Sjulin T. Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis. Cureus 2020; 12:e8587. [PMID: 32670722 PMCID: PMC7358928 DOI: 10.7759/cureus.8587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/12/2020] [Indexed: 11/05/2022] Open
Abstract
Deep vein thrombosis is a common condition encounter by hospitalists and managed by either oral or intravenous anti-coagulation. Although uncommon, phlegmasia cerulea dolens (PCD) is a life-threatening manifestation of acute deep vein thrombosis requiring early recognition and aggressive intervention to preserve life and limb. PCD is characterized by marked swelling of the lower extremities with pain and cyanosis, which often leads to gangrene and amputation. We present the case of a patient who developed PCD of her left lower extremity who was successfully treated with an EkoSonic™ endovascular catheter (Boston Scientific, Marlborough, MA, USA), which accelerates lytic dispersion of the thrombolytic drug through ultrasound technology.
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Affiliation(s)
- Chung-Ting J Kou
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Caitlin Batzlaff
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Matthew L Bezzant
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Tyson Sjulin
- Pulmonary and Critical Care, Brooke Army Medical Center, Fort Sam Houston, USA
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Heafner T, Nissen AP, Schechtman D, Alderete JF, Arthurs ZM, Propper BW. Venovenous bypass using continuous renal replacement therapy and endovascular inferior vena cava reconstruction to treat bilateral massive iliocaval deep venous thrombosis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:438-442. [PMID: 31660468 PMCID: PMC6806639 DOI: 10.1016/j.jvscit.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/11/2019] [Indexed: 11/25/2022]
Abstract
Many inferior vena cava (IVC) anomalies remain asymptomatic because of collateral circulation, but thrombosis of these channels can cause acute deep venous thrombosis with serious sequelae. For those with threatened limbs, anticoagulation is the mainstay of treatment, with endovascular pharmacomechanical thrombolysis replacing open surgical thrombectomy. Described is a severe case of massive iliocaval deep venous thrombosis with bilateral lower extremity Rutherford IIb acute limb ischemia in a patient with congenital IVC atresia. After initial thrombolysis, endovascular IVC reconstruction was accomplished to decompress the lower extremities. The patient ultimately required a right through-knee amputation but remains ambulatory with a prosthetic.
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Affiliation(s)
- Thomas Heafner
- San Antonio Military Medical Center, Fort Sam Houston, Tex
| | | | | | | | - Zachary M Arthurs
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md
| | - Brandon W Propper
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Md
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Liu X, Cao P, Li Y, Zhao J, Li L, Li H, Zhang Y. Safety and efficacy of pharmacomechanical thrombolysis for acute and subacute deep vein thrombosis patients with relative contraindications. Medicine (Baltimore) 2018; 97:e13013. [PMID: 30412139 PMCID: PMC6221726 DOI: 10.1097/md.0000000000013013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To evaluate the safety and efficacy of pharmacomechanical thrombolysis (PMT) performed for patients with relative contraindications.From June 2014 to December 2016, 112 patients with acute or subacute proximal deep vein thrombosis (DVT) were enrolled in this study. 60 patients (including 27 acute DVT patients and 33 subacute DVT patients) were treated with catheter-directed thrombolysis (CDT), and 52 patients with relative contraindications (including 25 acute DVT patients and 27 subacute DVT patients) with PMT. Assessment of venous recanalization was conducted using venography the time Inferior vena cava filter is removed, and complications were used to compare safety and efficacy between the groups.The outcomes of acute DVT patients no matter which kind of therapy performed, CDT or PMT, were significant better than subacute DVT patients (PCDT = .04 and PPMT = .01). However, there was no significant difference between CDT acute group and PMT acute group or between CDT subacute group and PMT subacute group (Pacute = .80 and Psubacute = .84). For complications of all patients, there was no mortality and major bleeding occurred.PMT could be a safe and effective management for DVT patients with relative contraindications, and the acute DVT may achieve better outcomes when they receive CDT or PMT.
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15
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Yang SS, Yun WS. Surgical Thrombectomy for Phlegmasia Cerulea Dolens. Vasc Specialist Int 2016; 32:201-204. [PMID: 28042562 PMCID: PMC5198769 DOI: 10.5758/vsi.2016.32.4.201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/10/2016] [Accepted: 10/13/2016] [Indexed: 11/20/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a medical emergency that can lead to venous gangrene of the lower extremity. Early diagnosis and prompt treatment is crucial for limb salvage. There are two treatment options (endovascular or surgical). In the endovascular era, catheter-directed thrombolysis is the treatment of choice to achieve venous outflow. However, surgical thrombectomy is indicated in certain cases. The authors report successful surgical thrombectomy in a 75-year-old man with PCD and review the treatment of PCD.
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Affiliation(s)
- Shin-Seok Yang
- Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Woo-Sung Yun
- Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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Min SK, Kim YH, Joh JH, Kang JM, Park UJ, Kim HK, Chang JH, Park SJ, Kim JY, Bae JI, Choi SY, Kim CW, Park SI, Yim NY, Jeon YS, Yoon HK, Park KH. Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines. Vasc Specialist Int 2016; 32:77-104. [PMID: 27699156 PMCID: PMC5045251 DOI: 10.5758/vsi.2016.32.3.77] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/28/2023] Open
Abstract
Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.
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Affiliation(s)
- Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Young Hwan Kim
- Department of Radiology, Keimyung University College of Medicine, Daegu,
Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University School of Medicine, Seoul,
Korea
| | - Jin Mo Kang
- Department of Surgery, Gachon University College of Medicine, Incheon,
Korea
| | - Ui Jun Park
- Department of Surgery, Keimyung University College of Medicine, Daegu,
Korea
| | - Hyung-Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu,
Korea
| | - Jeong-Hwan Chang
- Department of Surgery, Chosun University College of Medicine, Gwangju,
Korea
| | - Sang Jun Park
- Department of Surgery, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jang Yong Kim
- Department of Surgery, Catholic University College of Medicine,
Korea
| | - Jae Ik Bae
- Mint Intervention Clinic, Seongnam,
Korea
| | - Sun Young Choi
- Department of Radiology, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Chang Won Kim
- Department of Radiology, Pusan National University School of Medicine, Yangsan,
Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul,
Korea
| | - Nam Yeol Yim
- Department of Radiology, Chonnam National University College of Medicine, Gwangju,
Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University College of Medicine, Incheon,
Korea
| | - Hyun-Ki Yoon
- Department of Radiology, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ki Hyuk Park
- Department of Surgery, Daegu Catholic University College of Medicine, Daegu,
Korea
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18
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Lin SC, Mousa A, Bernheim J, Dayal R, Henderson P, Hollenbeck S, Kent KC, Faries PL. Endoluminal Recanalization in a Patient with Phlegmasia Cerulea Dolens Using a Multimodality Approach. Vasc Endovascular Surg 2016; 39:273-9. [PMID: 15920657 DOI: 10.1177/153857440503900309] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Phlegmasia cerulea dolens is a limb-threatening form of deep venous thrombosis and should be treated aggressively. The authors report a patient who presented with iliocaval and femoral deep venous thrombosis and posed an additional therapeutic challenge based on a recent history of heparin-induced thrombocytopenia. Catheter-directed pharmacologic thrombolysis and balloon venoplasty were applied in treatment. The direct thrombin inhibitor argatroban was used in place of heparin for concurrent anticoagulation. This multimodality endovascular approach (chemical and mechanical interventions) was successful in relieving the venous occlusion and salvaging the limb, while maintaining appropriate treatment for heparin-induced thrombocytopenia.
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Affiliation(s)
- Stephanie C Lin
- Department of Vascular Surgery, New York Presbyterian Hospital, Cornell University, Weill Medical School and Columbia University, College of Physicians and Surgeons, New York, NY 10021, USA
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19
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Bader KB, Haworth KJ, Shekhar H, Maxwell AD, Peng T, McPherson DD, Holland CK. Efficacy of histotripsy combined with rt-PA in vitro. Phys Med Biol 2016; 61:5253-74. [PMID: 27353199 DOI: 10.1088/0031-9155/61/14/5253] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Histotripsy, a form of therapeutic ultrasound that uses the mechanical action of microbubble clouds for tissue ablation, is under development to treat chronic deep vein thrombosis (DVT). We hypothesize that combining thrombolytic agents with histotripsy will enhance clot lysis. Recombinant tissue plasminogen activator (rt-PA) and rt-PA-loaded echogenic liposomes that entrain octafluoropropane microbubbles (OFP t-ELIP) were used in combination with highly shocked histotripsy pulses. Fully retracted porcine venous clots, with similar features of DVT occlusions, were exposed either to histotripsy pulses alone (peak negative pressures of 7-20 MPa), histotripsy and OFP t-ELIP, or histotripsy and rt-PA. Microbubble cloud activity was monitored with passive cavitation imaging during histotripsy exposure. The power levels of cavitation emissions from within the clot were not statistically different between treatment types, likely due to the near instantaneous rupture and destruction of OFP t-ELIP. The thrombolytic efficacy was significantly improved in the presence of rt-PA. These results suggest the combination of histotripsy and rt-PA could serve as a potent therapeutic strategy for the treatment of DVT.
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Affiliation(s)
- Kenneth B Bader
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
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20
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Vedantham S, Piazza G, Sista AK, Goldenberg NA. Guidance for the use of thrombolytic therapy for the treatment of venous thromboembolism. J Thromb Thrombolysis 2016; 41:68-80. [PMID: 26780739 PMCID: PMC4715849 DOI: 10.1007/s11239-015-1318-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Patients with venous thromboembolism (VTE) are prone to the development of both short-term and long-term complications that can substantially affect their functional capacity and quality of life. Patients with deep vein thrombosis (DVT) often develop recurrent VTE or the post-thrombotic syndrome, whereas patients with pulmonary embolism (PE) can develop long-term symptoms and functional limitations along a broad spectrum extending to full-blown chronic thromboembolic pulmonary hypertension. Clinicians who care for patients showing severe clinical manifestations of DVT and PE are often faced with challenging decisions concerning whether and how to escalate to more aggressive treatments such as those involving the use of thrombolytic drugs. The purpose of this chapter is to provide guidance on how best to individualize care to these patients.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway, Box 8131, St. Louis, MO, 63110, USA.
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21
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Abstract
Advances in image-guided, catheter-based interventions have shown great potential to improve outcomes in patients with venous thromboembolism. Catheter-directed thrombolysis has been shown in one randomized controlled trial to reduce the risk of post-thrombotic syndrome in patients with acute lower extremity deep vein thrombosis; data from a larger national institute of health trial are expected in early 2017. The use of catheter-directed thrombolysis is also being increasingly considered for patients with submassive or massive pulmonary embolism. Preliminary studies suggest that endovascular stent placement and ablative therapies may be used to reduce symptoms and improve quality of life in severely affected patients with established post-thrombotic syndrome. In this article, we summarize the risks and benefits of endovascular venous thromboembolism therapies as currently understood, highlight clinical situations where their benefit may outweigh risks, and describe ongoing and upcoming pivotal research initiatives with multidisciplinary participation.
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Affiliation(s)
- S Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
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22
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Vedantham S, Sista AK, Klein SJ, Nayak L, Razavi MK, Kalva SP, Saad WE, Dariushnia SR, Caplin DM, Chao CP, Ganguli S, Walker TG, Nikolic B. Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2014; 25:1317-25. [DOI: 10.1016/j.jvir.2014.04.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 02/07/2023] Open
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23
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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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24
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Rokni Yazdi H, Rostami N, Hakimian H, Mohammadifar M, Ghajarzadeh M. Successful catheter-directed venous thrombolysis in an ankylosing spondylitis patient with phlegmasia cerulea dolens. IRANIAN JOURNAL OF RADIOLOGY 2013; 10:81-5. [PMID: 24046784 PMCID: PMC3767019 DOI: 10.5812/iranjradiol.11748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 10/22/2012] [Accepted: 10/28/2012] [Indexed: 11/25/2022]
Abstract
Ankylosing spondylitis (AS) is an inflammatory rheumatic disease. Phlegmasia cerulea dolens is a severe form of deep vein thrombosis characterized by swelling, pain, and bluish discoloration. Treatment delay may cause venous gangrene, tissue ischemia, limb loss or death. Here, we present an AS case who presented with phlegmasia cerulea dolens and treated by catheter-directed thrombolysis.
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Affiliation(s)
- Hadi Rokni Yazdi
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Hadi Rokni Yazdi, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-9124136470, Fax: +98-2166581578, E-mail:
| | - Nematollah Rostami
- Department of Internal Medicine, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homa Hakimian
- Department of Internal Medicine, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohammadifar
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Ghajarzadeh
- Brain and Spinal Injury Research Center (BASIR), Tehran University of Medical Sciences, Tehran, Iran
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25
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Abstract
Randomized clinical trials have defined anticoagulation with unfractionated or low-molecular-weight heparin followed by warfarin as a standard therapy for acute deep venous thrombosis (DVT). Such treatment is highly effective in preventing recurrent venous thromboembolism with a low risk of bleeding, but provides imperfect protection against development of the post-thrombotic syndrome. Several strategies of early thrombus removal, including surgical venous thrombectomy, catheter-directed thrombolysis and pharmacomechanical thrombectomy have been developed with the goal of reducing the incidence of the post-thrombotic syndrome by restoring venous patency and preserving valvular function. Although clinical judgement and a consideration of the individual patient's medical condition and values are required, early thrombus removal strategies should be considered in selected patients with phlegmasia cerulea dolens and those with a first episode of acute iliofemoral thrombosis of less than 14 days duration.
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Affiliation(s)
- M H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
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26
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Cookson D, Caldwell S. Phlegmasia Caerulea Dolens in a Patient With an Inferior Vena Cava Filter: Treatment of Massive Iliocaval Thrombosis Using Local Intravenous Catheter-Directed Thrombolysis. Cardiovasc Intervent Radiol 2011; 35:1226-30. [DOI: 10.1007/s00270-011-0314-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 11/04/2011] [Indexed: 11/30/2022]
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27
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Erdoes LS, Ezell JB, Myers SI, Hogan MB, Lesar CJ, Sprouse LR. Pharmacomechanical Thrombolysis for Phlegmasia Cerulea Dolens. Am Surg 2011; 77:1606-12. [DOI: 10.1177/000313481107701230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Phlegmasia cerulea dolens (PCD) is limb-threatening. Traditional treatments are very morbid. We examine the efficacy of percutaneous treatment of PCD. Between May 2005 and September 2008, we treated 21 limbs in 20 patients with lower extremity PCD who were candidates for thrombolysis. Diagnosis was by clinical examination and duplex ultrasound. Catheter access to the deep venous system was obtained through a popliteal vein. Therapy used pulse spray thrombolysis with tissue plasminogen activator (tPA). Infusion catheters and adjunctive percutaneous techniques were used as indicated. Postoperatively, patients were treated with systemic anticoagulation, compression hose, and interval follow-up. Limbs were graded according to the CEAP classification. Twenty patients (13 male) were treated with a mean age of 55.8 years. Nine patients had hypercoagulable states, four May Thurner syndrome, three a history of cancer, one postcolon resection, one acute myocardial infarction, and one postfemoral vein puncture. All patients had resolution of PCD without the need for open surgery. The initial tPA dose was 19.5 mg with pulse spray thrombolysis. Infusion catheters were required in 18 patients and used for 16.1 hours (range, 8 to 36 hours) until complete thrombolysis. Venous angioplasty was necessary in 14 patients with nine of these requiring venous stents. One patient required above-knee amputation despite successful treatment of her PCD. Mean follow-up was 10.7 months (range, 1 to 39 months). All patients demonstrated no or minimal residual thrombus and intact valvular function and a mean clinical CEAP score of 2.4. Percutaneous treatment of PCD produced excellent results with minimal morbidity.
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Affiliation(s)
- Luke S. Erdoes
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
| | - Jessica B. Ezell
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
| | | | - Michael B. Hogan
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
| | - Christopher J. Lesar
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
| | - L. Richard Sprouse
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
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28
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Khan IR, Reeves JG, Riesenman PJ, Kasirajan K. Simultaneous Arterial and Venous Ultrasound-Assisted Thrombolysis for Phlegmasia Cerulea Dolens. Ann Vasc Surg 2011; 25:696.e7-10. [DOI: 10.1016/j.avsg.2011.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/16/2011] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
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29
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Phlegmasia cerulea dolens in a patient with chronic myelogenous leukemia—a case report. Int J Angiol 2011. [DOI: 10.1007/bf01637046] [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] Open
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30
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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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31
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Karthikesalingam A, Young E, Hinchliffe R, Loftus I, Thompson M, Holt P. A Systematic Review of Percutaneous Mechanical Thrombectomy in the Treatment of Deep Venous Thrombosis. Eur J Vasc Endovasc Surg 2011; 41:554-65. [DOI: 10.1016/j.ejvs.2011.01.010] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/10/2011] [Indexed: 12/16/2022]
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32
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1485] [Impact Index Per Article: 114.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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33
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Endovascular Treatment of Phlegmasia Cerulea Dolens with Impending Venous Gangrene: Manual Aspiration Thrombectomy as the First-Line Thrombus Removal Method. Cardiovasc Intervent Radiol 2010; 34:1214-21. [DOI: 10.1007/s00270-010-0042-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 10/20/2010] [Indexed: 12/24/2022]
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34
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Kuo I, Smith J, Abou-Zamzam AM. A multimodal therapeutic approach to phlegmasia cerulea dolens in a pediatric patient. J Vasc Surg 2010; 53:212-5. [PMID: 20875715 DOI: 10.1016/j.jvs.2010.07.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/27/2010] [Accepted: 07/28/2010] [Indexed: 11/27/2022]
Abstract
Phlegmasia cerulea dolens is a rare but serious complication of deep venous thrombosis, which can lead to arterial compromise, tissue ischemia, and gangrene. It typically presents in an elderly population often with coexistent malignancy. There have been no reported cases in the ambulatory pediatric population. The authors report a case of a 5-year-old girl who presented with acute, extensive left lower extremity deep venous thrombosis resulting in phlegmasia cerulea dolens. Pharmacologic and mechanical interventions as described in the adult population were utilized. This case demonstrates that an aggressive, multimodal approach to phlegmasia cerulea dolens can be employed in the pediatric population and result in successful limb salvage.
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Affiliation(s)
- Isabella Kuo
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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35
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Gogalniceanu P, Johnston C, Khalid U, Holt P, Hincliffe R, Loftus I, Thompson M. Indications for Thrombolysis in Deep Venous Thrombosis. Eur J Vasc Endovasc Surg 2009; 38:192-8. [DOI: 10.1016/j.ejvs.2009.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 03/18/2009] [Indexed: 12/31/2022]
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36
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Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, Hofmann LV, Janne d'Othée BM, Antonaci VP, Brountzos EN, Brown DB, Martin LG, Matsumoto AH, Meranze SG, Miller DL, Millward SF, Min RJ, Neithamer CD, Rajan DK, Rholl KS, Schwartzberg MS, Swan TL, Towbin RB, Wiechmann BN, Sacks D. Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2009; 20:S227-39. [DOI: 10.1016/j.jvir.2009.04.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 11/12/2005] [Indexed: 10/20/2022] Open
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37
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Gociman B, Castillo-Sang M, Margni M, Almaroof B, Nazzal M. Successful Treatment of Phlegmasia Cerulea Dolens with Combination Surgical and Catheter-Assisted Thrombectomy. Vascular 2009; 17:108-11. [DOI: 10.2310/6670.2008.00057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Phlegmasia cerulea dolens is a rare condition caused by complete venous occlusion that leads to impaired arterial flow. Prompt diagnosis and treatment initiation are paramount in preventing progression to gangrene, the need for amputation, and possibly the death of the patient. Thrombolysis or surgical thrombectomy, for advanced disease and cases in which anticoagulation is contraindicated, represent the current standard treatment. Here we report the case of a 47-year-old male who sustained severe trauma during a car accident. After having a prophylactic retrievable inferior vena cava filter placed, he developed caval thrombosis with progression to phlegmasia cerulea dolens. He was successfully treated with a combination of surgical thrombectomy of the lower extremity veins and catheter-assisted thrombectomy of the iliac veins and inferior vena cava, in the setting in which an initial attempt at balloon thrombectomy of the iliac veins and inferior vena cava failed. He was discharged from the hospital in stable condition and on follow-up visits had full resolution of symptoms. Ultrasound evaluation showed no residual venous clot. The presented case illustrates how the use of catheter-assisted thrombectomy alleviated the need for a laparotomy and direct caval evacuation of the thrombus and provided a timely and effective treatment of phlegmasia cerulea dolens with impending gangrene.
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Affiliation(s)
- Barbu Gociman
- *Department of Surgery, †Division of Vascular Surgery, The University of Toledo Health Science Center, Toledo, OH
| | - Mario Castillo-Sang
- *Department of Surgery, †Division of Vascular Surgery, The University of Toledo Health Science Center, Toledo, OH
| | - Mohmmed Margni
- *Department of Surgery, †Division of Vascular Surgery, The University of Toledo Health Science Center, Toledo, OH
| | - Babatunde Almaroof
- *Department of Surgery, †Division of Vascular Surgery, The University of Toledo Health Science Center, Toledo, OH
| | - Munier Nazzal
- *Department of Surgery, †Division of Vascular Surgery, The University of Toledo Health Science Center, Toledo, OH
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38
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Abstract
This article focuses on the clinical presentation, diagnosis, and management of veno-thromboembolism, including deep venous thrombosis (DVT) and pulmonary embolism (PE), from the perspective of the emergency physician. The discussion is divided into two sections: DVT and PE. Because veno-thromboembolism is a continuum, certain aspects, such as background, incidence, the use of D dimer, and anticoagulation of both DVT and PE, are discussed together. Heavier emphasis is placed on topics germane to the emergency physician, and considerations for special populations are reviewed.
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Affiliation(s)
- J Matthew Fields
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Ground Ravdin Building, Philadelphia, PA 19104, USA
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39
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Hua HT, Albadawi H, Entabi F, Conrad MF, Stoner MC, Houser S, Watkins MT. Effects of acute global venous obstruction and unfractionated heparin on muscle cytokine synthesis. Ann Vasc Surg 2008; 23:108-15. [PMID: 18640815 DOI: 10.1016/j.avsg.2008.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 05/05/2008] [Accepted: 05/09/2008] [Indexed: 10/21/2022]
Abstract
Phlegmasia cerulea dolens is a devastating complication of massive deep venous thrombosis, which is clinically characterized by massive lower extremity tissue edema and subsequent arterial insufficiency. These experiments evaluated the local tissue effects of acute global venous obstruction combined with partial arterial ischemia. Experiments were performed to assess the effects of heparin on the cytokine response to simultaneous venous and partial arterial obstruction. Murine hind limbs were subjected to conditions of unilateral venous occlusion and partial tourniquet limb ischemia, which was confirmed by laser Doppler imaging (LDI). Mice underwent either hind limb venous obstruction with intravenous unfractionated heparin (200IU/kg) or intravenous saline 5min before venous occlusion. Sham-treated mice were subjected to anesthesia alone without venous occlusion. After 3hr, the mice were killed and tissue was harvested for measurement of edema (wet to dry weight ratio, W/D), muscle viability, indices of local thrombosis (thrombin-antithrombin complex [TAT]), and cytokine analysis for growth-related oncogene-1 (GRO-1) and interleukin-6 (IL-6, protein via enzyme-linked immunoassay and mRNA via reverse transcriptase polymerase chain reaction). Bleeding time and volume were documented in saline- and heparin-treated mice to confirm systemic anticoagulation. Administration of intravenous heparin resulted in a marked increase in bleeding time and volume. LDI confirmed venous obstruction and ongoing arterial inflow. Venous obstruction resulted in severe visible edema that correlated with a significantly higher W/D ratio but was not associated with a significant decrease in muscle viability. GRO-1 and IL-6 protein and mRNA levels were significantly elevated in the venous occlusion group compared to sham. Heparin therapy significantly decreased TAT3 levels but did not alter the profile of GRO-1 or IL-6 protein levels seen with venous occlusion. Venous occlusion with partial ischemia induces a unique and potent local cytokine expression. Heparin therapy did not ameliorate the cytokine response. These data indicate that heparin therapy does not modulate the cytokine response to venous obstruction.
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Affiliation(s)
- Hong T Hua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Oguzkurt L, Tercan F, Ozkan U. Manual Aspiration Thrombectomy with Stent Placement: Rapid and Effective Treatment for Phlegmasia Cerulea Dolens with Impending Venous Gangrene. Cardiovasc Intervent Radiol 2007; 31:205-8. [PMID: 17710467 DOI: 10.1007/s00270-007-9156-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Revised: 07/18/2007] [Accepted: 07/24/2007] [Indexed: 11/30/2022]
Abstract
Phlegmasia cerulea dolens is an uncommon but potentially life-threatening complication of acute deep vein thrombosis. It is an emergency and delay in treatment may cause death or loss of the patient's limb. Surgical thrombectomy is the recommended treatment in venous gangrene. Catheter-directed intrathrombus thrombolysis has been reported as successful, but it may require a lengthy infusion. Manual aspiration thrombectomy may clear the entire thrombus with no need for thrombolytic administration and provide rapid and effective treatment for patients with phlegmasia cerulea dolens with impending venous gangrene.
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Affiliation(s)
- Levent Oguzkurt
- Department of Radiology, Baskent University Faculty of Medicine, Ankara, Turkey.
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Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, Hofmann LV, Janne d'Othée BM, Antonaci VP, Brountzos EN, Brown DB, Martin LG, Matsumoto AH, Meranze SG, Miller DL, Millward SF, Min RJ, Neithamer CD, Rajan DK, Rholl KS, Schwartzberg MS, Swan TL, Towbin RB, Wiechmann BN, Sacks D. Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2006; 17:435-47; quiz 448. [PMID: 16567668 DOI: 10.1097/01.rvi.0000197348.57762.15] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Suresh Vedantham
- Department of Radiology, Mallinckrodt Institute of Radiology, Saint Louis, Missouri, USA
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Navarro F, Dean S. Young patients with iliofemoral deep venous thrombosis should receive thrombolytic therapy. Med Clin North Am 2003; 87:1165-77. [PMID: 14680298 DOI: 10.1016/s0025-7125(03)00112-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 20-year-old otherwise healthy woman on oral contraceptive pills presents with sudden-onset left leg swelling and pain extending from her calf to her groin. Pulmonary embolism symptoms are lacking. Venous duplex ultrasound reveals acute deep venous thrombosis (DVT) involving the distal external iliac, common femoral, superficial femoral, and popliteal veins. Her leg is markedly swollen, slightly cool to the touch, but has preserved pedal pulses. She is unable to ambulate secondary to pain. Thrombolytic therapy to eliminate the DVT is recommended.
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Affiliation(s)
- Felipe Navarro
- North Central Heart Institute, 4520 West 69th Street, Sioux Falls, SD 57016, USA.
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Elsharawy M, Elzayat E. Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical trial. Eur J Vasc Endovasc Surg 2002; 24:209-14. [PMID: 12217281 DOI: 10.1053/ejvs.2002.1665] [Citation(s) in RCA: 296] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE catheter directed thrombolysis has been advocated for complete and rapid dissolution of iliofemoral deep venous thrombosis (DVT). The aim of our study is to compare, in a randomised trial, local thrombolysis and anticoagulation with anticoagulation alone in patients with iliofemoral DVT. METHODS a consecutive series of 35 eligible patients, were randomised to either catheter directed thrombolysis followed by anticoagulation or to anticoagulation alone. Clot lysis and deep venous reflux were assessed with ultrasound duplex and plethysmography after 6 months. RESULTS complete data were available in the 18 and 17 patients randomised to thrombolysis and anticoagulation, respectively. At 6 months, patency rate was better in cases treated with thrombolysis [13/18 (72%) vs 2/17 (12%), p < 0.001]. Venous reflux was higher in-patients treated with anticoagulant [7 patients (41%) vs 2 (11%), p = 0.04]. CONCLUSION in the short-term patients treated with catheter directed thrombolysis obtained better patency and competence than those treated with standard anticoagulation.
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Bergan JJ. COMMENTARY: A Major Step Forward in the Treatment of Venous Occlusion. J Endovasc Ther 2000. [DOI: 10.1583/1545-1550(2000)007<0092:amsfit>2.3.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Affiliation(s)
- J J Bergan
- Department of Surgery, University of California San Diego, USA.
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