Phlegmasia Cerulea Dolens

Right Lower Extremity Phlegmasia Cerulea Dolens Due to Iliotibial Vein Thrombosis With Compartment Syndrome and Circulatory Shock: Case Report and Review

Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication of extensive deep vein thrombosis (DVT) characterized by severe pain, swelling, and cyanosis of the affected limb. It results from total or near-total occlusion of the deep and superficial veins of a limb, leading to venous congestion and ischemia. It is associated with 40% mortality, more commonly affecting the left lower extremity, with up to 50% of patients requiring limb amputations. PCD complicated by compartment syndrome (CS) with shock and multiorgan failure is very rare. We report the case of a 55-year-old female who presented with sudden onset, severe right lower extremity pain and swelling with associated limb discoloration, paresthesias, and inability to move the toes of her right foot. On examination, there was cyanosis, pulselessness, and tense right leg and thigh compartments. Doppler ultrasonography revealed DVT of the right external iliac extending to the posterior tibial vein. A diagnosis of PCD with CS was made and the patient was immediately started on anticoagulation with unfractionated heparin and emergent decompressive fasciotomies of the right leg and thigh were performed. Following the fasciotomies, she developed circulatory shock and went into cardiac arrest. Despite successful resuscitation, her hemodynamic instability and multiorgan failure precluded further life-saving interventions including thrombolysis or thrombectomy. Limb amputation was declined given her poor prognosis and she passed away shortly thereafter. This case illustrates the rare occurrence of right lower extremity PCD complicated by CS, circulatory shock, and multiorgan failure, which can sometimes occur despite emergency fasciotomy but can be averted with prompt intervention. These complications often preclude immediate thrombolysis and/or thrombectomy. Its recognition, therefore, warrants timely and more aggressive interventions to prevent limb loss or death.

Phlegmasia cerulea dolens: a swelling, cyanosis and discolouration of the extremity in the ICU

Phlegmasia cerulea dolens is a rare entity that causes critical limb ischaemia, which may lead to amputation of the limb and may be life-threatening. Here, we describe a case of a healthy man in his 50s with multiple trauma who was transferred to the intensive care unit (ICU) of a central hospital for neuromonitoring following splenectomy for the stabilisation of a hypovolaemic shock. On admission to the ICU, the patient developed a swollen and white leg. The condition was caused by early compromised arterial flow secondary to extensive deep vein thrombosis.

Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report

BACKGROUND

COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both.

CASE PRESENTATION

A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated.

CONCLUSIONS

This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

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.

Upper limb phlegmasia cerulea dolens treated with single-session suction thrombectomy: a case report

Phlegmasia cerulea dolens (PCD) of the lower limbs is a rare condition. PCD of the upper limbs is extremely uncommon, with only a select few cases documented in the literature. A complication of severe deep venous thrombosis, PCD, is characterized by the clinical triad of oedema, pain and limb cyanosis. Delays in treatment are associated with high rates of morbidity and mortality. We present a case of sudden-onset upper limb PCD in a 68-year-old man following haemodialysis through a long-term arteriovenous fistula. Prompt diagnosis and rapid initiation of intravenous anticoagulation followed by urgent single-session suction thrombectomy resulted in the successful restoration of vessel patency without any significant adverse sequelae on 3-month follow-up.

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.

Pulseless Electrical Activity Arrest as the First Symptom of Testicular Cancer with Subsequent Phlegmasia Cerulea Dolens

Introduction

Phlegmasia cerulea dolens (PCD) is a severe, rare complication of deep vein thrombosis, which is characterised by compartment syndrome, arterial compromise, venous gangrene, and shock. Prothrombotic states are the primary risk factor for PCD, which, in most cases, is associated with pulmonary embolism and carries a high mortality.

Case report

A 46-year-old male presented following a pulseless electrical activity (PEA) arrest due to saddle pulmonary embolism (PE). He subsequently developed PCD and venous gangrene secondary to inferior vena cava obstruction, in the setting of a new diagnosis of testicular germ cell tumour.

Discussion

PEA arrest, as the initial presenting problem in malignancy, is rare. It is extreme for the first indication of cancer to be a PEA arrest from massive PE. While hypoxic brain injury from the cardiac arrest precluded intervention in this case, a surgical approach entailing en bloc resection of aortocaval metastasis, with subsequent IVC reconstruction, followed by lower limb venous thrombectomy would have been favoured as it was considered that an endovascular approach would not have been successful.

Conclusion

A case of a patient with phlegmasia cerulea dolens secondary to testicular cancer, who presented following PEA arrest is described.

Bilateral Phlegmasia Cerulea Dolens After Warfarin Reversal for Acute Rectal Bleeding: A Case Report

BACKGROUND

Deep vein thrombosis (DVT) is a common disease that is diagnosed in approximately 1 in 1000 adults annually. Extensive DVT can lead to life- or limb-threatening diagnoses such as phlegmasia cerulea dolens (PCD), phlegmasia alba dolens, and venous gangrene. PCD, also known as massive iliofemoral venous thrombosis, is rare, and a severe complication of DVT.

CASE REPORT

We report a case of a 94-year-old bedridden woman with past medical history of dementia, hypertension, pulmonary embolism, DVT, and atrial fibrillation. The patient was admitted to the hospital for bright red blood per rectum and an elevated international normalized ratio (INR) of 5.7. On admission, her dose of warfarin was suspended and she was given 4 units of fresh frozen plasma as well as 10 mg of i.v. vitamin K. She was discharged home with an INR normalized to 1.3 and cessation of her rectal bleeding. At discharge, she was not restarted on warfarin, nor was any bridging therapy used. The patient returned to the Emergency Department a week later for worsening pain and bluish discoloration of her bilateral lower extremities. An ultrasound (US) examination showed that she had developed bilateral PCD, after INR reversal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians commonly care for patients who present with acute DVT or treat patients on anticoagulant therapy who require cessation of medications or administration of prothrombotic agents to reverse bleeding. Cases of extensive clot burden leading to PCD have been reported in the literature, however, reports of bilateral PCD secondary to cessation of warfarin have been scarce. PCD should be considered carefully as one of the complications in warfarin reversal, as it requires immediate attention and surgical intervention to prevent limb loss.

Management of Post-Traumatic Phlegmasia Cerulea Dolens via Right-to-Left Femoral Vein to Femoral Vein Bypass (Palma Procedure)

Phlegmasia cerulea dolens (PCD) is a rare condition resulting from venous occlusion that impairs arterial flow. We report a rare case of post-traumatic PCD after ligation of the iliac vein with successful treatment by right-to-left femoral vein to femoral vein bypass using left great saphenous vein (Palma procedure). The clinical presentation, diagnostic process, and approach to management along with a literature review on the operative management of PCD are presented in this case report.

Phlegmasia Cerulea Dolens as an Unusual Presentation of Ruptured Abdominal Aortic Aneurysm into the Inferior Vena Cava

The aim of this case study is to report a case of unusual manifestation of ruptured abdominal aortic aneurysm (AAA) involving an aortocaval fistula (ACF) as phlegmasia cerulea dolens (PCD). A 58-year-old male presented with acute signs of PCD of the right lower limb, confirmed on duplex ultrasonography. Computed tomography angiography revealed a 65-mm ruptured AAA with a large ACF. Successful emergent surgical repair was performed, using implantation of an aortobi-iliac graft with primary closure of the fistula and associated venous thrombectomy. PCD revealing a ruptured AAA with ACF is rare. Knowledge of this original entity might be the most important factor on the outcome.

Efficacy of histotripsy combined with rt-PA in vitro

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.

Phlegmasia Cerulea Dolens in the Pediatric Population: A Life-threatening Condition

BACKGROUND

Phlegmasia cerulea dolens is a rare complication of deep venous thromboembolism that can have life-threatening consequences. It is more commonly reported in the adult population, and rarely in the pediatric population, especially in a healthy child.

CASE REPORT

We report a case of a healthy 7-year-old girl who presented with right leg pain and fever, found to have a thrombus involving her inferior vena cava and right lower extremity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of early recognition and a multimodal approach to treatment of phlegmasia cerulea dolens.

Phlegmasia cerulea dolens after coronary artery bypass surgery: what should we know

Phlegmasia cerulea dolens (PCD) is one of the most critical disorders of acute deep vein thrombosis in that it can cause permanent disability secondary to the compartment syndrome. Although several etiological factors have been proposed, PCD after coronary artery bypass surgery is extremely rare and its definitive pathophysiology is still under debate. We herein present a case of PCD that resulted in the compartment syndrome after coronary artery bypass surgery. Early recognition and decompression of PCD are crucial for saving the affected limbs.