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Otto AM, Ciampa ML, Martin ED. Lacunar cerebral infarction following endovascular interventions for phlegmasia cerulea dolens. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:536-539. [PMID: 34401620 PMCID: PMC8358278 DOI: 10.1016/j.jvscit.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Ashley M Otto
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Md
| | - Maeghan L Ciampa
- Department of Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga
| | - Eric D Martin
- Department of Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga
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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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Said A, Sahlieh A, Sayed L. A comparative analysis of the efficacy and safety of therapeutic interventions in phlegmasia cerulea dolens. Phlebology 2020; 36:392-400. [PMID: 33236674 DOI: 10.1177/0268355520975581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ahmad Said
- Department of Internal Medicine, Department of Cardiovascular Medicine, 7005Beaumont Health, Troy, MI, USA
- Clinical Instructor of Medicine, 6918Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Ali Sahlieh
- Department of Internal Medicine, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Luay Sayed
- Department of Internal Medicine, Department of Cardiovascular Medicine, 7005Beaumont Health, Troy, MI, USA
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Vetrhus M, Vennesland JB, Hasan SIO, Fjetland L. Phlegmasia cerulea dolens secondary to an aortoiliac aneurysm. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:278-282. [PMID: 31312778 PMCID: PMC6610647 DOI: 10.1016/j.jvscit.2019.03.008] [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: 01/16/2019] [Accepted: 03/13/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Morten Vetrhus
- Vascular Surgery Unit, Department of Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Samir Issa Othman Hasan
- Interventional Radiology Unit, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
| | - Lars Fjetland
- Interventional Radiology Unit, Department of Radiology, Stavanger University Hospital, Stavanger, Norway
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ELsaid AS, AlQattan AS, Elashaal E, AlSadery H, AlGhanmi I, Aldhafery BF. The ugly face of deep vein thrombosis: Phlegmasia Cerulea Dolens-Case report. Int J Surg Case Rep 2019; 59:107-110. [PMID: 31128546 PMCID: PMC6535643 DOI: 10.1016/j.ijscr.2019.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/27/2019] [Accepted: 05/07/2019] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ayman S ELsaid
- Department of General Surgery King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Abdullah Saleh AlQattan
- Medical Intern, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia.
| | - Ehab Elashaal
- Department of General Surgery King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Humood AlSadery
- Demonstrator, Department of General surgery - Division of Vascular Surgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Ibrahim AlGhanmi
- Department of Radiology King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Bander Fuhaid Aldhafery
- Department of Radiology King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Saudi Arabia
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Wang W, Sun R, Chen Y, Liu C. Meta-analysis and systematic review of percutaneous mechanical thrombectomy for lower extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2018; 6:788-800. [DOI: 10.1016/j.jvsv.2018.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/05/2018] [Indexed: 01/01/2023]
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[Phlebological emergencies]. Hautarzt 2018; 69:384-391. [PMID: 29637225 DOI: 10.1007/s00105-018-4160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Greenberg J, Troutman DA, Shubinets V, Dougherty MJ, Calligaro KD. Phlegmasia Cerulea Dolens in the Upper Extremity. Vasc Endovascular Surg 2016; 50:98-101. [DOI: 10.1177/1538574416631645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Zeboulon C, Amy de la Bretèque M, Bilan P, Sin C, Linder JF, Dakhil B, Sigal ML, Mahé E. [Phlegmasia cerulea dolens]. Ann Dermatol Venereol 2014; 141:682-4. [PMID: 25442472 DOI: 10.1016/j.annder.2014.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/01/2014] [Accepted: 06/19/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- C Zeboulon
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - M Amy de la Bretèque
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - P Bilan
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - C Sin
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - J-F Linder
- Laboratoire d'explorations vasculaires, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - B Dakhil
- Service de chirurgie thoracique et vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - M-L Sigal
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France
| | - E Mahé
- Service de dermatologie et médecine vasculaire, centre hospitalier Victor-Dupouy, 69, rue du Lieutenant-Colonel-Prud'hon, 95107 Argenteuil cedex, France.
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Fulminant phlegmasia cerulea dolens with concurrent cholangiocarcinoma and a lupus anticoagulant: a case report and review of the literature. Blood Coagul Fibrinolysis 2014; 25:507-11. [PMID: 24553060 DOI: 10.1097/mbc.0000000000000057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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