Lacunar cerebral infarction following endovascular interventions for phlegmasia cerulea dolens

Phlegmasia cerulea dolens is a rare presentation of deep venous thrombus treated with catheter directed thrombolysis and pharmacomechanical thrombectomy. This is the case of a 78-year-old woman who underwent catheter directed thrombolysis to treat phlegmasia cerulea dolens and subsequently developed left-sided hemiplegia and expressive aphasia in the setting of an international normalized ratio of 2.0. Further imaging revealed a lacunar infarct in the right thalamus with a middle cerebral artery distribution. Further workup revealed a patent foramen ovale. We highlight the unexpected enigmatic consequence from multimodal endovascular intervention, the consequence of long-term inferior vena cava filters.

Phlegmasia cerulea dolens following internal hemipelvectomy: Case report and literature review

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.

A comparative analysis of the efficacy and safety of therapeutic interventions in phlegmasia cerulea dolens

OBJECTIVE

Present an institution's experience in management of phlegmasia cerulea dolens (PCD) with a review of the literature.

METHODS

Beaumont Health's electronic record database was queried between July 2009 and November 2019 for inpatients with PCD. A comprehensive chart review was performed to verify the accuracy of the diagnosis and extract relevant parameters. Medians and proportions are reported.

RESULTS

22 patients met the criteria for PCD. 59% females. Median age 65 years (interquartile range [IQR] 22). Obesity was present in 45% of patients. 18 patients underwent either a single modality (55.5%) or a multimodality therapeutic approach (44.5%). Limb amputation was required in a third of patients who underwent catheter-directed thrombolysis or percutaneous thrombectomy alone. Death was highest after percutaneous thrombectomy alone (66%) followed by pharmacomechanical catheter-directed thrombolysis alone (50%).

CONCLUSION

Percutaneous interventions have become the mainstay in management of PCD as demonstrated in this large retrospective analysis and supported by literature review.

Phlegmasia cerulea dolens secondary to an aortoiliac aneurysm

Phlegmasia cerulea dolens is an uncommon entity. We present a case of phlegmasia cerulea dolens secondary to an aortoiliac aneurysm that compressed the common iliac vein. Catheter-directed thrombolysis was not considered to be a suitable option, because the patient needed an urgent fasciotomy. The aneurysm was treated with a bifurcated stent graft and the thrombosed veins were opened with pharmacomechanical thrombectomy and recombinant tissue plasminogen activator. The reopened iliac veins, including an aneurysmal external iliac vein, were stented and fasciotomy was performed. Pharmacomechanical thrombectomy can be performed with a low dose of recombinant tissue plasminogen activator and allows for subsequent surgery.

The ugly face of deep vein thrombosis: Phlegmasia Cerulea Dolens-Case report

INTRODUCTION

Phlegmasia Cerulea Dolens (PCD), a rare & life-threatening condition caused by a massive deep venous thrombosis that is associated with arterial occlusion caused by the subsequent compartment syndrome.

CASE PRESENTATION

A 56-year-old male was diagnosed as a case of extensive left femoral DVT & pulmonary embolism. Two days after being managed by systemic thrombolytics & heparin, his condition worsened as he developed cyanosis of the affected limb, compartment syndrome & foot drop so he was referred to our facility for further management. CT venogram showed a thrombosis of the left popliteal vein extending into the left common iliac vein confirming the diagnosis of PCD & May-Turner syndrome. We adopted a limb preserving approach using a pharmacomechanical catheter directed thrombolysis (PCDT). The patient recovered fully with a complete resolution of his foot drop.

DISCUSSION

Several treatment options have been suggested to improve the outcomes of PCD, but due to the rarity of this condition a gold standard treatment is still controversial. But regardless of the chosen approach, there is an urgent need to decrease the thrombus burden to prevent further adverse sequelae like amputation or even death which can be achieved by using PCDT as it was demonstrated in our case.

CONCLUSION

Our case shows that a rare entity of DVT as PCD could be a result of improper management of acute proximal DVT in the background of anatomical variabilities & that despite the late presentation of such a rare condition there still a role for a limb preserving approach with endovascular techniques.

[Phlebological emergencies]

BACKGROUND

Deep and superficial vein thromboses as well as variceal hemorrhages are emergencies. The risk of short- and long-term morbidity and mortality in vein thromboses is increased. Variceal hemorrhage harbors the risk of massive blood loss. Prompt and adequate therapy of these diseases is therefore essential.

OBJECTIVES

Our aim was to give an overview of these phlebological emergencies.

MATERIALS AND METHODS

Based on the current guidelines and supplemented by a selective literature search in PubMed, we summarize the most important aspects for clinical practice.

RESULTS

In deep vein thrombosis, therapeutic anticoagulation and compression therapy are indicated for a duration of at least 3-6 months. A shorter duration is associated with a considerably increased recurrence rate. Basic measures in superficial vein thrombosis comprise mobilization, cooling, and compression. In case of tenderness on palpation, non-steroidal anti-inflammatory drugs are recommended. Indication for anticoagulation and its dose depends on length of the thrombus and distance of the proximal part of the thrombus towards the deep veins. Variceal hemorrhage is a complication of advanced varicosis and can usually be handled with simple measures such as elevation of the extremity and compression.

CONCLUSIONS

Prompt diagnosis and therapy is essential in superficial and deep vein thrombosis to prevent short-term complications such as pulmonary embolism and growth of the thrombus as well as long-term complications such as postthrombotic syndrome with secondary varicosis and chronic leg ulcer. After the occurrence of varicophlebitis or variceal hemorrhage, treatment of varicosis is indicated to prevent recurrences.

Phlegmasia Cerulea Dolens in the Upper Extremity

Phlegmasia cerulea dolens (PCD) is a rare form of venous gangrene that arises secondary to occlusion of venous outflow from a limb. Classically described in the lower extremity, it is rare in the upper extremity. We present a case report of upper extremity PCD and a systematic review with data analysis of 37 cases of PCD published in PubMed. Our analysis showed that concurrent lower extremity PCD was a statistically significant marker for worse outcomes in this patient population.

[Phlegmasia cerulea dolens]

BACKGROUND

Herein we report a case of phlegmasia cerulea dolens, a form of venous thrombosis complicated by arterial ischaemia.

PATIENTS AND METHODS

A 69-year-old man presented a bilateral trophic condition of the lower limbs that had appeared 3 weeks earlier. The patient had a history of metastatic urothelial bladder carcinoma and arteritis. Clinical examination revealed right leg ulcers with massive bilateral oedema of the lower limbs, cyanosis and local ischaemia. Doppler ultrasound revealed bilateral and proximal deep vein thrombosis (sural and superficial femoral veins of the right leg; sural and iliac veins of the left leg) without any distal arterial flow. We concluded on a diagnosis of bilateral phlegmasia cerulea dolens.

DISCUSSION

Phlegmasia cerulea dolens is a particular type of deep venous thrombosis in which a proximal venous thrombus is combined with arterial ischaemic signs due to brutal and massive oedema and slowing down of arterial flow. In most cases, the lower limbs are involved, with malignancy being the most common cause. It should be suspected in the presence of the classical triad of "pain, oedema and cyanosis", with confirmation by Doppler ultrasound. There is no general consensus regarding standard management. Traditionally, systemic anticoagulation has been the mainstay of treatment for this condition. Endovascular surgery may be a possibility in some cases. Prompt diagnosis and rapid treatment initiation are paramount in order to improve the prognosis of this severe condition with ominous prospects.

Fulminant phlegmasia cerulea dolens with concurrent cholangiocarcinoma and a lupus anticoagulant: a case report and review of the literature

Phlegmasia cerulea dolens (PCD) is an aggressive and life-threatening form of venous thrombosis complicated by ischemic necrosis. Massive thrombosis extends to collateral veins resulting in venous congestion with fluid sequestration in the interstitium causing collapse of arterioles, which progresses to ischemia and, if severe, circulatory collapse and shock. The mortality rate for PCD is as high as 40%, especially when gangrene develops. PCD has been associated with acquired thrombophilias, including malignancy and antiphospholipid syndrome (APS). We present a unique case of a patient with PCD refractory to anticoagulant and thrombolytic therapy, whose fulminant course was attributed to concurrent cholangiocarcinoma and antiphospholipid antibodies identified by a positive lupus anticoagulant assay. This case highlights the importance of uncovering precipitating causes of thromboembolism, which may offer prognostic information and may necessitate therapy beyond anticoagulation and thrombolysis to reduce the morbidity of PCD. The current literature on PCD and APS, along with their associations with malignancy, is reviewed.