1
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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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2
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Ge J, Weng C, Zhao J, Yuan D, Wang T. Upper extremity phlegmasia cerulea dolens complicating supra vena cava embolism in a cervical cancer patient: case report. Front Cardiovasc Med 2024; 11:1351358. [PMID: 38385133 PMCID: PMC10880184 DOI: 10.3389/fcvm.2024.1351358] [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: 12/06/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare yet severe complication of deep vein thrombosis (DVT), characterized by a high amputation rate and mortality. Early diagnosis and treatment are crucial in managing this condition. PCD predominantly affects the lower extremities rather than the upper extremities. We herein present a rare upper extremity PCD case accompanied with supra vena cava and pulmonary embolism in a cervical cancer patient, who presented to our institution with severe pain, edema and irreversible venous gangrene of right upper limb with no response to anticoagulation therapy. Emergency fasciotomy and amputation were performed due to the progressed venous gangrene, however, the patient developed severe infection and coagulation disorders, gastrointestinal bleeding and disseminated intravascular coagulation after the surgery. Despite medical interventions, her family chose to withdraw treatment and the patient died in ICU at the fourth day following emergency surgery.
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Affiliation(s)
| | | | | | | | - Tiehao Wang
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
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3
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Arnold J, Koyfman A, Long B. High risk and low prevalence diseases: Acute limb ischemia. Am J Emerg Med 2023; 74:152-158. [PMID: 37844359 DOI: 10.1016/j.ajem.2023.09.052] [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: 06/05/2023] [Revised: 08/26/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization. CONCLUSIONS An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jacob Arnold
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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4
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Melchor J, Leong K, Edwards JB. Phlegmasia cerulea dolens of the upper extremity treated with anticoagulation and leech therapy. J Vasc Surg Cases Innov Tech 2023; 9:101296. [PMID: 37767354 PMCID: PMC10520443 DOI: 10.1016/j.jvscit.2023.101296] [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: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 09/29/2023] Open
Abstract
Phlegmasia cerulea dolens is a serious manifestation of venous thrombosis that has a high risk of morbidity and mortality. If not promptly treated on presentation, progressive extremity ischemia and potential gangrene can lead to emergency amputation of the affected limb. Most commonly, the lower extremities are affected, and reports of upper extremity phlegmasia are scarce. We report the successful treatment of phlegmasia cerulea dolens of the distal upper extremity using leech therapy combined with anticoagulation.
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Affiliation(s)
- Julian Melchor
- Sarasota Regional Medical School Campus, Florida State University College of Medicine, Sarasota, FL
| | - Kenneth Leong
- Department of Plastic Surgery, Sarasota Memorial Hospital, Sarasota, FL
| | - Jeffrey B. Edwards
- Department of Vascular Surgery, Sarasota Vascular Specialists, Sarasota, FL
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5
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Burt JN, Hirsh JD, Panchal RM, Endler GT, Devalla RN, Mitchell ME, Villalobos MA. Inferior Vena Cava Filter Occlusion Causing Phlegmasia Alba Dolens. Am Surg 2023; 89:3915-3916. [PMID: 37204767 DOI: 10.1177/00031348231177929] [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] [Indexed: 05/20/2023]
Abstract
Phlegmasia alba dolens is a rare sequela of acute extensive venothrombus of the iliofemoral segments. Rarely, phlegmasia alba dolens can also result from clotted inferior vena cava filter. A 39-year-old with protein S deficiency, and prior inferior vena cava filter placement after remote trauma presented to the emergency department with progressive bilateral lower extremity pain and swelling. Venous duplex revealed extensive bilateral deep vein thromboses from the external iliac veins to popliteal veins, as well as thrombophlebitis of the left great saphenous vein. Venography confirmed patency of the suprarenal vena cava with abrupt occlusion of the infrarenal segment at the level of the inferior vena cava filter. The filter was removed followed by endovascular thrombectomy and adjunctive venoplasty. The patient progressed well and discharged on therapeutic anticoagulation. This case illustrates that a staged endovascular approach may be utilized for acute on chronic caval thrombosis and filter removal.
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Affiliation(s)
- Jeremy N Burt
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
| | - Joshua D Hirsh
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
| | - Ramola M Panchal
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
| | - Graham T Endler
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
| | - Raviteja N Devalla
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
| | - Marc E Mitchell
- Department of Surgery, University of Mississippi Medical Center Jackson, MS, USA
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6
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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] [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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7
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Kang JW, Kim KT, Park JW, Lee SJ. Classification of deep vein thrombosis stages using convolutional neural network of electromyogram with vibrotactile stimulation toward developing an early diagnostic tool: A preliminary study on a pig model. PLoS One 2023; 18:e0281219. [PMID: 36730258 PMCID: PMC9894458 DOI: 10.1371/journal.pone.0281219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/18/2023] [Indexed: 02/03/2023] Open
Abstract
Deep vein thrombosis (DVT) can lead to life-threatening disorders; however, it can only be recognized after its symptom appear. This study proposed a novel method that can detect the early stage of DVT using electromyography (EMG) signals with vibration stimuli using the convolutional neural networks (CNN) algorithm. The feasibility of the method was tested with eight legs before and after the surgical induction of DVT at nine-time points. Furthermore, perfusion pressure (PP), intracompartmental pressure (IP), and shear elastic modulus (SEM) of the tibialis anterior were also collected. In the proposed method, principal component analysis (PCA) and CNN were used to analyze the EMG data and classify it before and after the DVT stages. The cross-validation was performed in two strategies. One is for each leg and the other is the leave-one-leg-out (LOLO), test without any predicted information, for considering the practical diagnostic tool. The results showed that PCA-CNN can classify before and after DVT stages with an average accuracy of 100% (each leg) and 68.4±20.5% (LOLO). Moreover, all-time points (before induction of DVT and eight-time points after DVT) were classified with an average accuracy of 72.0±11.9% which is substantially higher accuracy than the chance levels (11% for 9-class classification). Based on the experimental results in the pig model, the proposed CNN-based method can classify the before- and after-DVT stages with high accuracy. The experimental results can provide a basis for further developing an early diagnostic tool for DVT using only EMG signals with vibration stimuli.
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Affiliation(s)
- Jong Woo Kang
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Keun-Tae Kim
- Bionics Research Center, Korea Institute of Science and Technology, Seoul, Republic of Korea
| | - Jong Woong Park
- Department of Orthopaedic Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Song Joo Lee
- Bionics Research Center, Korea Institute of Science and Technology, Seoul, Republic of Korea
- Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology, Seoul, Republic of Korea
- * E-mail:
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8
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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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9
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Single-Stage Endovascular Thrombectomy and Stenting as the First-Line Strategy in the Treatment of Phlegmasia Cerulea Dolens Caused by Iliac Vein Lesions. Ann Vasc Surg 2023; 92:149-154. [PMID: 36681270 DOI: 10.1016/j.avsg.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Phlegmasia cerulea dolens (PCD) is a rare and serious complication of deep venous thrombosis and iliac vein lesions (IVLs) are the most common cause of PCD. The purpose of this study was to explore the safety and efficacy of single-stage endovascular thrombus removal and stenting to treat PCD caused by IVLs. METHODS Clinical data of 13 patients with PCD secondary to IVL were retrospectively analyzed. They underwent endovascular thrombus removal, including rheolytic thrombectomy, manual aspiration thrombectomy, and simultaneous iliac vein stenting after thrombus removal. The safety and efficacy of single-stage endovascular thrombectomy and stenting in the treatment of PCD were evaluated. RESULTS The technical success rate was 100% (13/13). Postoperative symptoms were significantly relieved in all patients. There were no perioperative major bleeding complications or other critical adverse events. Two (15.4%) patients had slightly elevated serum creatinine concentration after surgery, which returned to normal before discharge. At the 12-month follow-up, the stent primary patency rate was 81.8% and there were no cases of severe post-thrombotic syndrome. CONCLUSIONS Single-stage endovascular thrombectomy and stenting in PCD due to IVLs was minimally invasive, safe, and effective; it is recommended as a first-line treatment for PCD caused by IVLs.
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10
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Carey M, Alser O, Leist J, Sorrells K, Bankhead BK, Li W. Delayed onset phlegmasia cerulea dolens post-SARS-CoV-2 infection treated with minimally invasive clot retrieval technology. J Vasc Surg Cases Innov Tech 2022; 9:101082. [PMID: 36568022 PMCID: PMC9762486 DOI: 10.1016/j.jvscit.2022.11.019] [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: 05/19/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
Coronavirus disease 2019 is associated with a significant venous thromboembolic risk. Phlegmasia cerulean dolens is a severe form of deep vein thrombosis that can lead to acute limb ischemia. In this report, we present a 58-year-old woman who developed a delayed-onset left lower extremity phlegmasia cerulean dolens 8 weeks after coronavirus disease 2019 onset that led to compartment syndrome and acute limb ischemia from external compression of the arterial vasculature from edematous muscle. The patient received an emergent minimally invasive percutaneous mechanical thrombectomy and four-compartment fasciotomy, resulting in adequate perfusion and ultimately made a full recovery.
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Affiliation(s)
- Michael Carey
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Osaid Alser
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Jessica Leist
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Kelsee Sorrells
- Surgical ICU Services, University Medical Center, Lubbock, TX
| | - Brittany K. Bankhead
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Wei Li
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
- Correspondence: Wei Li, MD, MPH, MJ, RPVI, RVT, FACS, Department of Surgery, 3601 4th St, MS #8312, Texas Tech University Health Sciences Center, Lubbock, TX 79415
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11
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Muacevic A, Adler JR, Ngwudike C, Tripathi M. Right Lower Extremity Phlegmasia Cerulea Dolens Due to Iliotibial Vein Thrombosis With Compartment Syndrome and Circulatory Shock: Case Report and Review. Cureus 2022; 14:e32364. [PMID: 36628047 PMCID: PMC9826733 DOI: 10.7759/cureus.32364] [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] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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12
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Phlegmasia cerulea dolens causing compartment syndrome. Am J Emerg Med 2022; 61:234.e1-234.e3. [PMID: 35961832 DOI: 10.1016/j.ajem.2022.08.009] [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: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Phlegmasia cerulea dolens (PCD) is a rare condition characterized by a severely swollen, cyanotic, blue extremity due to a large proximal (iliofemoral) deep venous thrombosis extending into the collateral veins. Mortality in PCD ranges 20-40%. Due to severely compromised venous drainage, compartment pressures can rapidly increase 16-fold within 6 h, but rarely result in arterial compromise. CASE REPORT We present a case of a middle-aged woman with no prior history of deep venous thrombosis, with a blue swollen left leg in intractable severe pain unresponsive to 3 doses of hydromorphone. Her pain was successfully alleviated with IV Lidocaine. Patient was found to have phlegmasia cerulea dolens resulting in compartment syndrome of her left leg. Although the patient initially had no motor function, after catheter-directed thrombolysis and emergent thrombectomy, she regained her motor function and made a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Phlegmasia cerulea dolens complicated by severe compartment syndrome is a rare entity. Prompt recognition and treatment are necessary to prevent irreversible limb ischemia and associated morbidity and mortality. IV Lidocaine may be considered as an option for analgesia for such patients.
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13
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Trinidad B, Berman SS, Labropoulos N, Pacanowski J, Yanquez F, Chen W, Leon LR. Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis. Vasc Endovascular Surg 2022; 56:797-801. [PMID: 35921088 DOI: 10.1177/15385744221084148] [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: 11/16/2022]
Abstract
The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.
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Affiliation(s)
- Bradley Trinidad
- Department of Surgery, Division of Vascular Surgery, 22165University of Arizona Medical Center, Tucson, AZ, USA
| | - Scott S Berman
- Department of Surgery, Division of Vascular Surgery, 22165University of Arizona Medical Center, Tucson, AZ, USA.,Vascular and Endovascular Surgery Staff, Pima Heart Physicians, Tucson, AZ, USA
| | - Nicos Labropoulos
- Department of Vascular and Endovascular Surgery at Stony Brook, Stony Brook University hospital, Long Island, NY, USA
| | - John Pacanowski
- Department of Surgery, Division of Vascular Surgery, 22165University of Arizona Medical Center, Tucson, AZ, USA.,Vascular and Endovascular Surgery Staff, Pima Heart Physicians, Tucson, AZ, USA
| | | | - Winsor Chen
- Department of Surgery, Division of Vascular Surgery, 22165University of Arizona Medical Center, Tucson, AZ, USA
| | - Luis R Leon
- Department of Surgery, Division of Vascular Surgery, 22165University of Arizona Medical Center, Tucson, AZ, USA.,Vascular and Endovascular Surgery Staff, Pima Heart Physicians, Tucson, AZ, USA
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14
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Hembd A, Kim H, Lahsaei P, Haddock NT, Teotia SS. Upper-Extremity Phlegmasia Cerulea Dolens With Compartment Syndrome in Coronavirus Disease 2019 Sepsis. J Hand Surg Am 2022; 47:693.e1-693.e3. [PMID: 34127316 PMCID: PMC8096192 DOI: 10.1016/j.jhsa.2021.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 02/17/2021] [Accepted: 04/28/2021] [Indexed: 02/02/2023]
Abstract
A 54-year-old woman with leukemia presented with coronavirus disease 2019 and a right upper-extremity indwelling peripherally inserted central catheter line for chemotherapy administration. On hospital admission day 9, she developed acute right upper-extremity edema and pain. Ultrasound demonstrated complete superficial and deep venous thrombosis up to the proximal subclavian vein. Her examination result was consistent with acute phlegmasia cerulea dolens and compartment syndrome, but respiratory instability prevented transfer and vascular surgery intervention. Instead, we performed bedside fasciotomies and administered therapeutic heparin, and the limb was salvaged. This case underscores the potential for successful limb salvage in patients with phlegmasia in the setting of coronavirus disease 2019 via compartment release and therapeutic anticoagulation.
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Affiliation(s)
- Austin Hembd
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Hannah Kim
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peiman Lahsaei
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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15
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Geary A, Arinze N, Shean K, King E, Merrill AL. A 41-Year-Old Woman with a Cold Foot. NEJM EVIDENCE 2022; 1:EVIDmr2200106. [PMID: 38319258 DOI: 10.1056/evidmr2200106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
A 41-Year-Old Woman with a Cold FootA 41-year-old woman presented for evaluation of a painful and cold right foot. How do you approach the evaluation, and what is the diagnosis?
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Affiliation(s)
- Alaina Geary
- from the General Surgery Residency Program and Vascular Surgery Fellowship Program, Boston Medical Center
| | - Nkiruka Arinze
- from the General Surgery Residency Program and Vascular Surgery Fellowship Program, Boston Medical Center
| | - Katie Shean
- from the General Surgery Residency Program and Vascular Surgery Fellowship Program, Boston Medical Center
| | - Elizabeth King
- from the General Surgery Residency Program and Vascular Surgery Fellowship Program, Boston Medical Center
| | - Andrea L Merrill
- from the General Surgery Residency Program and Vascular Surgery Fellowship Program, Boston Medical Center
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16
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Reverse Takutsubo Cardiomyopathy in a Patient with Phlegmasia Cerulea Dolens. Case Rep Cardiol 2022; 2022:5413237. [PMID: 35783160 PMCID: PMC9242792 DOI: 10.1155/2022/5413237] [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: 04/06/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
Reverse takotsubo cardiomyopathy (rTTC) is a rare variant of takotsubo cardiomyopathy (TTC) which is characterized by reversible left ventricular (LV) dysfunction. Emotional and physical stress have been implicated in triggering TTC especially in postmenopausal women. TTC and its variants are becoming more recognized due to the widespread adoption of early coronary angiography in the setting of acute coronary syndromes. A man in his late 50s presented to the emergency department with left lower extremity pain, swelling, and cyanosis. Clinical assessment was consistent with phlegmasia cerulea dolens, with deep venous thrombosis detected by venous duplex ultrasound. During his admission, he developed clinical and EKG findings suggestive of acute coronary syndrome. Emergent coronary angiography and ventriculography revealed basal and midventricular hypokinesis with hyperdynamic left ventricular apex, depressed LV dysfunction without coronary artery obstruction diagnostic of reverse takotsubo cardiomyopathy. Venous thromboembolism is a rare finding but has been associated with takotsubo cardiomyopathy and should be considered in the appropriate setting.
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17
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Hindi H, Dongmo G, Goodwin A, Jones S, Loveridge K. Imaging findings and interventional management of deep venous thrombosis. J Clin Imaging Sci 2022; 12:26. [PMID: 35673592 PMCID: PMC9168300 DOI: 10.25259/jcis_221_2021] [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: 12/13/2021] [Accepted: 04/03/2022] [Indexed: 11/04/2022] Open
Abstract
Deep venous thrombosis (DVT) is a subtype of venous thromboembolism. Lower extremity DVT affects about 1-2% of hospitalized patients. If not managed properly, these thrombi can embolize, causing further complications. Thrombosis risk factors include vascular endothelial injury, venous stasis, and hypercoagulability states. This triad is also known as Virchow’s triad. Although clinical features of lower extremity DVT are nonspecific and many patients are asymptomatic, physicians should maintain a high index of suspicion in patients presenting with leg swelling, pain, warmth, and erythema. Several diagnostic approaches for suspected first DVT have been proposed, and management depends on multiple factors such as location, duration of symptoms, cause of the thrombosis, and recurrence rate.
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Affiliation(s)
- Hussam Hindi
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States,
| | - Gauthier Dongmo
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States,
| | - Alyssa Goodwin
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States,
| | - Sean Jones
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States,
| | - Kristian Loveridge
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, United States,
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18
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Omar Mohamed Ozaal AM, Fernando T. Deep vein thrombosis in an elderly patient with chronic limb-threatening ischaemia presented with limb swelling: The role of diagnostic tools and surgical dilemma. SAGE Open Med Case Rep 2022; 10:2050313X221089121. [PMID: 35401979 PMCID: PMC8984839 DOI: 10.1177/2050313x221089121] [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: 01/11/2022] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
Leg and foot swelling is inherently found in 70% of patients with critical
limb-threatening ischaemia due to ischaemia, which does not necessitate any specific
intervention. Unilateral leg swelling is a vital sign for the clinical suspicion and
diagnosis of deep vein thrombosis and phlegmasia. There is a significant surgical dilemma
to delay the diagnosis of deep vein thrombosis or phlegmasia in patients with critical
limb-threatening ischaemia when a methodical approach is not followed. We report a case of
proximal deep vein thrombosis in an elderly patient with ipsilateral critical
limb-threatening ischaemia and discuss the role of diagnostic tools. The role of
antiplatelets along with vitamin K antagonists, duration of anticoagulation, iliocaval
venous obstruction, compression therapy and inferior vena cava filter is discussed.
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19
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A rare coexistence of acute thrombotic occlusion
of the left popliteal-tibioperoneal artery and the left iliofemoral vein: a case report. Arch Med Sci Atheroscler Dis 2022; 7:e1-e4. [PMID: 35582711 PMCID: PMC9081907 DOI: 10.5114/amsad.2022.114939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/14/2022] [Indexed: 11/17/2022] Open
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20
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Ruben-Castillo C, Cuen-Ojeda C, Lopez-Peña G, Anaya-Ayala JE, Hinojosa CA. Surgical Intervention for Phlegmasia Cerulea Dolens in a 61-Year-Old Cancer Patient. Tex Heart Inst J 2022; 49:477163. [DOI: 10.14503/thij-20-7400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Phlegmasia cerulea dolens, a rare and potentially fatal complication of acute deep vein thrombosis, is characterized by substantial edema, intense pain, and cyanosis. Phlegmasia cerulea dolens may compromise limb perfusion and lead to acute ischemia, gangrene, amputation, and death. We present the case of a 61-year-old woman with a history of breast cancer who had signs and symptoms of phlegmasia cerulea dolens in her left leg. She was treated promptly with open surgical thrombectomy and sequential distal compression with use of an Esmarch bandage to ensure complete thrombus extraction. These techniques restored venous flow and saved her leg. Open surgical thrombectomy should be considered in the presence of limb-threatening acute deep vein thrombosis presenting as phlegmasia cerulea dolens.
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Affiliation(s)
- Christopher Ruben-Castillo
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Cesar Cuen-Ojeda
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriel Lopez-Peña
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier E. Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A. Hinojosa
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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21
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Talib U, Talib A. Blue Leg: Phlegmasia Cerulea Dolens Secondary to May Thurner Syndrome. Cureus 2022; 14:e21105. [PMID: 35165564 PMCID: PMC8830386 DOI: 10.7759/cureus.21105] [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] [Accepted: 01/11/2022] [Indexed: 11/05/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) can present as leg pain accompanied by bluish discoloration. It is a limb-threatening emergency that needs to be promptly addressed with anticoagulation with consideration of thrombolytics. We present a case of PCD in an 83-year-old female without obvious risk factor for thrombosis, found to have May Thurner Syndrome (MTS) requiring a chemical and mechanical approach to prevent catastrophic outcomes.
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22
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Alghamdi L, Alattab N, Alwohaibi A, Alotaibi YH, AlSheef M. Phlegmasia Cerulea Dolens Secondary to COVID-19 and May-Thurner Syndrome: A Case Report. Cureus 2022; 14:e21301. [PMID: 35186563 PMCID: PMC8847406 DOI: 10.7759/cureus.21301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 12/28/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is associated with significant thromboembolic risk. Extensive deep vein thrombosis can infrequently progress to phlegmasia cerulea dolens that carries high morbidity and mortality rates. We report a case of a middle-aged male presenting with phlegmasia cerulea dolens in the context of COVID-19 and underlying May-Thurner syndrome, associated with transiently positive antiphospholipid antibodies.
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23
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Ibrahim B, Kattimani R. Phlegmasia Cerulea Dolens, a Deadly Complication of Deep Vein Thrombosis: Case Report and Review of Literature. Cureus 2021; 13:e19927. [PMID: 34966616 PMCID: PMC8710803 DOI: 10.7759/cureus.19927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 11/05/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare limb and life-threatening condition caused by extensive deep vein thrombosis of the extremities, and it is classically associated with extensive oedema, severe pain, and skin mottling, which may lead to compartment syndrome, venous gangrene, and even death. A 40-year-old male, with a background history of right femoral vein thrombosis, cardiomyopathy, with an ejection fraction of only 10%, presented with three days history of progressive swelling, pain, and discolouration of the right lower limb. He was treated with therapeutic low molecular weight heparin along with supportive care with intravenous fluids and pain relief. In view of his poor ejection fraction, he was treated non-operatively with supportive care. The patient succumbed after three months of presentation. PCD is a rare vascular emergency condition that if not recognized early and treated aggressively may lead to higher morbidity and mortality.
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Affiliation(s)
- Ban Ibrahim
- Emergency Medicine, Sunderland and South Tyneside NHS Trust, Newcastle Upon Tyne, GBR
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24
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Galanakis N, Kontopodis N, Kehagias E, Daskalakis N, Tsetis K, Ioannou CV, Tsetis D. Direct Iliac Vein Stenting in Phlegmasia Cerulea Dolens Caused by May-Thurner Syndrome. Vasc Specialist Int 2021; 37:37. [PMID: 34959225 PMCID: PMC8720580 DOI: 10.5758/vsi.210031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/19/2021] [Accepted: 12/03/2021] [Indexed: 11/20/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is an uncommon but potentially limb-threatening complication of acute deep vein thrombosis. A 56-year-old male presented with PCD. Color Doppler ultrasonography revealed extensive thrombosis of the left superficial and common femoral and external and common iliac veins. After an unsuccessful iliofemoral thrombectomy, contrast-enhanced computed tomography revealed iliofemoral deep vein thrombosis due to May-Thurner syndrome (MTS). After the deployment of an inferior vena cava filter, the thrombotic occlusion was traversed with a guidewire and direct stenting was performed to achieve immediate recanalization. The patient was discharged two days after the procedure, demonstrating significant clinical improvement. MTS is a rare cause of PCD. Direct iliac vein stenting may be a safe and effective alternative treatment for rapid recanalization if percutaneous mechanical thrombectomy devices are unavailable.
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Affiliation(s)
- Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Daskalakis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Konstantinos Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
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25
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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26
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Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg 2021; 79:122-126. [PMID: 34644637 PMCID: PMC8502248 DOI: 10.1016/j.avsg.2021.07.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/17/2021] [Accepted: 07/18/2021] [Indexed: 12/30/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has been widely reported to be associated with increased risk of Venous Thromboembolism, both deep vein thrombosis (DVT) and pulmonary embolism. A rare and extreme manifestation of DVT is Phlegmasia cerulea dolens, characterized by poor tissue perfusion due to marked limb swelling which can progress to limb and life-threatening venous gangrene. We report the case of a 53-year-old man with severe SARS-CoV2 pneumonia who developed acute iliofemoral DVT leading to acute limb ischemia due to Phlegmasia cerulea dolens. The patient underwent successful emergent fasciotomy and mechanical thrombectomy with removal of extensive thrombus burden and restoration of normal venous circulation. Our case highlights the importance of clinical vigilance and early implementation of therapeutic interventions to avoid adverse outcomes in patients who develop SARS-CoV2 induced Venous Thromboembolism complications.
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Affiliation(s)
- Josue R Gutierrez
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | | | - Edvard Skripochnik
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | - Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY.
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27
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Moghbel MC, Chen Z, Liu CM, Rajan S, Vempaty HT, Wang SL. Thrombotic Risk Associated with Inferior Vena Cava Filter Placement in Patients with Heparin-Induced Thrombocytopenia. J Vasc Interv Radiol 2021; 32:1629-1634. [PMID: 34547476 DOI: 10.1016/j.jvir.2021.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/23/2021] [Accepted: 08/08/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This study sought to define thromboembolic risk and mortality in patients with heparin-induced thrombocytopenia (HIT) undergoing inferior vena cava filter (IVCF) placement, in light of the American Society of Hematology's 2018 guidelines against routine use of IVCFs in this population. METHODS A total of 26 patients with HIT who received IVCFs were retrospectively reviewed, and the outcomes of this group were compared with those of 4,707 controls with either HIT or IVCFs alone and with reported outcomes in prior studies. RESULTS The patient group demonstrated 6- and 12-month mortality rates of 26.9% and 30.8%, respectively, which did not differ significantly from those of the control groups and were in line with published mortality rates in the literature. The measured thromboembolic risk of 19.2% in the patient group was also within the range of published rates for patients with HIT or IVCF alone. CONCLUSIONS IVCF placement did not significantly increase the risk of thromboembolism or death in patients with HIT and may be a viable option in the subset of these patients who are not candidates for anticoagulation.
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Affiliation(s)
- Mateen C Moghbel
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Zeng Chen
- Section of Geriatric Medicine, Stanford University Medical Center, Stanford, California
| | - Chi-Mei Liu
- Department of Graduate Medical Education, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Sudhir Rajan
- Department of Pulmonology & Critical Care, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Hyma T Vempaty
- Department of Hematology & Oncology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Stephen L Wang
- Department of Radiology, Division of Vascular & Interventional Radiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
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28
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Sukovatykh BS, Sereditskiĭ AV, Azarov AM, Muradian VF, Sukovatykh MB, Lapinas AA. [Case of effective endovascular treatment of venous gangrene]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:147-152. [PMID: 34528599 DOI: 10.33529/angio2021306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Presented in this article is a clinical case report regarding treatment of a patient with deep vein thrombosis complicated by venous gangrene having developed 10 days after the onset of the disease. Conservative therapy (infusion of colloids and crystalloids, anticoagulants, agents improving microcirculation, venotonics, nonsteroidal anti-inflammatory drugs, elevated position of the limb) made it possible to stabilize the patient's condition, but not improving haemodynamics of the affected limb. A decision was made to use endovascular techniques. Treatment was carried out in three stages. The first stage during 48 hours consisted in regional catheter thrombolysis with urokinase, exerting a minimal clinical effect. The second stage was percutaneous mechanical thrombectomy after which the diameter of thrombosed veins became free by half, with the beginning of disease regression. The third stage consisted in venous stenting of residual stenosis of the iliac vein, resulting in normalization of the venous outflow from the affected limb. A conclusion was drawn on feasibility of combined use of regional thrombolysis, percutaneous mechanical thrombectomy, and venous stenting in treatment of venous gangrene.
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Affiliation(s)
- B S Sukovatykh
- Department of General Surgery, Kursk State Medical University, Kursk, Russia
| | - A V Sereditskiĭ
- Department of Endovascular Surgery, Orel Regional Clinical Hospital, Orel, Russia
| | - A M Azarov
- Department of Endovascular Surgery, Orel Regional Clinical Hospital, Orel, Russia
| | - V F Muradian
- Department of Endovascular Surgery, Orel Regional Clinical Hospital, Orel, Russia
| | - M B Sukovatykh
- Department of General Surgery, Kursk State Medical University, Kursk, Russia
| | - A A Lapinas
- Department of Endovascular Surgery, Orel Regional Clinical Hospital, Orel, Russia
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29
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Anane O, Rezziki A, Benzirar A, El Mahi O. Phlegmasia cerulea dolens during the SARS-COV-2 pandemic: What management ? Ann Med Surg (Lond) 2021; 67:102541. [PMID: 34249354 PMCID: PMC8254390 DOI: 10.1016/j.amsu.2021.102541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 11/08/2022] Open
Abstract
PCD is a serious disease, because of its important morbi-mortality. The suspicion of COVID-19 in front of any severe deep vein thrombosis. Aponeurotomy and rapid medical management of compartment syndrome, can reduce the morbidity and mortality of phlegmasia cerulea dolens. Blue phlebitis or also called ischemic phlebitis; is a real medico-surgical emergency.
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Affiliation(s)
- Oussama Anane
- Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco.,University Hospital Center Mohamed VI, Oujda, Morocco
| | - Abdellah Rezziki
- Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco.,University Hospital Center Mohamed VI, Oujda, Morocco
| | - Adnane Benzirar
- Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco.,University Hospital Center Mohamed VI, Oujda, Morocco
| | - Omar El Mahi
- Mohammed First University, Faculty of Medicine and Pharmacy, Oujda, Morocco.,University Hospital Center Mohamed VI, Oujda, Morocco
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30
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Pearce EK. An Uncommon Cause of Shock: Acute Thrombosis of the Inferior Vena Cava. J Emerg Med 2021; 61:67-69. [PMID: 33972133 DOI: 10.1016/j.jemermed.2021.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Obstructive shock is an uncommon presentation to the emergency department (ED) and is most often caused by an acute pulmonary embolism. A very rare cause of obstructive shock is extensive deep venous thrombosis, otherwise known as phlegmasia cerulea dolens. We present a case of obstructive shock caused by placement of an inferior vena cava filter complicated by acute occlusion with extensive deep venous thrombosis. CASE REPORT A 57-year-old man presented to the ED with hypotension, lethargy, and chronic leg pain. The day prior he had an inferior vena cava filter placed and was taken off his anticoagulation approximately 1 week prior. Massive pulmonary embolism was excluded as the cause based on point-of-care ultrasound showing absence of right heart strain. His initial resuscitation and evaluation did not determine the cause of his shock and he was empirically treated for sepsis. After adequate blood pressure was achieved with norepinephrine, his lower extremities were noted to be cyanotic and an ultrasound revealed the diagnosis of phlegmasia cerulea dolens. The shock state resolved after catheter-directed thrombolysis. Why Should an Emergency Physician Be Aware of This? Although unique, this case highlights an alternative cause of obstructive shock and informs emergency physicians about a potential deadly complication of a common procedure.
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31
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Smith T, Kahre J, Sargsyan Z. Phlegmasia Cerulea Dolens Related to Urinary Retention. Am J Med 2021; 134:e339-e340. [PMID: 33238138 DOI: 10.1016/j.amjmed.2020.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 09/30/2020] [Accepted: 09/30/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Travis Smith
- Lake Erie College of Osteopathic Medicine, Bradenton Fla.
| | - Jarrod Kahre
- Lake Erie College of Osteopathic Medicine, Bradenton Fla
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32
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Suciadi LP, Aristo AN. Phlegmasia Alba Dolens Complicating Rhabdomyolysis. Cureus 2021; 13:e14080. [PMID: 33786250 PMCID: PMC7992910 DOI: 10.7759/cureus.14080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 57-year-old woman with obesity, severe dyslipidemia and hypertension presented with acute onset of excruciating pain at left leg followed by entire leg swelling without a specific provocation. Physical examination revealed a significant left lower limb oedema along with pale skin, livedo reticularis, poikilothermia, and diminished distal artery pulsation. Urgent vascular Doppler sonography of left lower limb showed obstructive venous thrombus and non-compressible vessel at level of iliofemoral vein. Arterial systems were without any obliteration but with relatively reduced flow to distal part. Blood test resulted in significantly raised creatinine and creatine kinase (CK) level. Diagnosis of phlegmasia alba dolens with complication of rhabdomyolysis and acute kidney injury had been made initially. The patient was treated with heparin as well as rehydration using saline solution and bicarbonate. Eventually, she had clinical improvement during hospitalization and been discharged with resolution of creatinine and CK level.
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Affiliation(s)
- Leonardo P Suciadi
- Cardiology, Siloam Hospitals Kebon Jeruk/Siloam Heart Institute, Jakarta, IDN
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33
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Avdeev SN, Nekludova GV, Tsareva NA, Yaroshetskiy AI, Merzhoeva ZM, Nuralieva GS, Trushenko NV. Pain, Swelling and Blue Discoloration of Right Hand in a COVID-19 Patient. Ann Emerg Med 2021; 77:650-657. [PMID: 34030779 PMCID: PMC7836820 DOI: 10.1016/j.annemergmed.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Sergey N Avdeev
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Galina V Nekludova
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia A Tsareva
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Andrey I Yaroshetskiy
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Zamira M Merzhoeva
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Galia S Nuralieva
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalia V Trushenko
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Jensen J, Ladner J, Mann R, Kitley C. Successful thrombectomy and thrombolysis of deep vein thrombosis in a patient with acute phlegmasia cerulea dolens with May-Thurner anatomy. Radiol Case Rep 2021; 16:631-637. [PMID: 33437345 PMCID: PMC7788493 DOI: 10.1016/j.radcr.2020.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/08/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare and important diagnosis to consider in the setting of a painful, swollen, and cyanotic lower extremity. We report a 59-year-old female diagnosed with PCD 3 days status post extended head and neck surgery with additional imaging findings concerning for May-Thurner anatomy. This case presentation is pathognomonic for PCD. Risk factors, pathogenesis, and management are described.
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Affiliation(s)
- John Jensen
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Joshua Ladner
- Madigan Army Medical Center, Department of Radiology, 9040A Jackson Av, Tacoma, WA 98431 USA
| | - Ryan Mann
- Madigan Army Medical Center, Department of Radiology, 9040A Jackson Av, Tacoma, WA 98431 USA
| | - Charles Kitley
- Madigan Army Medical Center, Department of Radiology, 9040A Jackson Av, Tacoma, WA 98431 USA
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Flegmasia cerúlea dolens and venous gangrena associated with infection by SARS-CoV-2: case report and literature review. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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36
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Bamgboje A, Hong J, Mushiyev S, Pekler G. A 61-Year-Old Man with SARS-CoV-2 Infection and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb Consistent with Phlegmasia Cerulea Dolens. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e928342. [PMID: 33323917 PMCID: PMC7750909 DOI: 10.12659/ajcr.928342] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Male, 61-year-old Final Diagnosis: Phlegmasia cerulea dolens Symptoms: Bilateral leg swelling • breathlessness • cough • fever Medication: — Clinical Procedure: — Specialty: Cardiology • Infectious Diseases • Medicine, General and Internal
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Affiliation(s)
- Abayomi Bamgboje
- Department of Internal Medicine, NYC Health+Hospitals/Metropolitan, New York City, NY, USA
| | - Jungrak Hong
- Department of Internal Medicine, NYC Health+Hospitals/Metropolitan, New York City, NY, USA
| | - Savi Mushiyev
- Department of Cardiology, NYC Health+Hospitals/Metropolitan, New York City, NY, USA
| | - Gerald Pekler
- Department of Cardiology, NYC Health+Hospitals/Metropolitan, New York City, NY, USA
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Tan G, Yan BP. A new treatment paradigm for phlegmasia cerulea dolen: Single stage endovascular pharmacomechanical thrombectomy with venoplasty and stenting. Phlebology 2020; 36:456-463. [PMID: 33323066 DOI: 10.1177/0268355520977276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Phlegmasia Cerulae Dolen (PCD) is potentially a lethal disease but there is currently no established treatment algorithm for it. The aim of this study was to assess the safety and effectiveness of single stage endovascular pharmacomechanical thrombectomy with venoplasty and stenting in the treatment of PCD. METHOD This was a retrospective single centre observational study of consecutive patients who underwent endovascular intervention for the treatment of PCD between June 2016 and March 2020. Clinical and procedural details were recorded. Procedural and clinical success rate, procedural complications, and 30 days mortality were reported. RESULT 11 patients were treated during the study period. 2 (18.2%) had active malignancy. 63.6% were uncomplicated PCD on presentation. Common iliac vein compression or stenosis were demonstrated in all patients. Venous stents were implanted in all cases and procedures were successful in all cases. All patients had symptoms improvement at 72 hours post procedure. Other than 2 major bleeding complications, there was no other adverse event. The 30 days mortality was 18.2%. Active malignancy and the presence of anaemia were significantly associated with major complications. CONCLUSION Single stage endovascular thrombectomy and stenting was effective and safe in the treatment of patients with PCD. Common Iliac vein compression was a common underlying cause of PCD.
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Affiliation(s)
- GuangMing Tan
- Division of Cardiology, Department of Medicine and Therapeutic, Prince of Wales Hospital, Shatin, New Territory, Hong Kong SAR
| | - Bryan Py Yan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR
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38
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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: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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39
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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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Midulla M, Chevallier O, Comby PO, Giordano G, Pescatori LC, Falvo N, van den Berg JC, Cariati M, Loffroy R. Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020. Catheter Cardiovasc Interv 2020; 98:748-755. [PMID: 33185318 DOI: 10.1002/ccd.29375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 11/11/2022]
Abstract
Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.
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Affiliation(s)
- Marco Midulla
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Olivier Chevallier
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Pierre-Olivier Comby
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Giuseppe Giordano
- Diagnostic and Interventional Radiology, ARNAS Garibaldi-Nesima, Catania, Italy
| | - Lorenzo Carlo Pescatori
- Department of Radiology, CHU Henri-Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France
| | - Nicolas Falvo
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Jos C van den Berg
- Service of Interventional Radiology, Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland.,Inselspital, Universitätsspital Bern Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Bern, Switzerland
| | - Maurizio Cariati
- Department of Radiology, Ospedale Universitario Santi Carlo e Paolo, Milan, Italy
| | - Romaric Loffroy
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
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Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:653-656. [PMID: 33102992 PMCID: PMC7571495 DOI: 10.1016/j.jvscit.2020.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/01/2020] [Indexed: 12/11/2022]
Abstract
Patients with acute coronavirus disease 2019 (COVID-19) respiratory infection are associated with concomitant thromboembolic complications and a hypercoagulable state. Although these mechanisms are not completely understood, unique alterations in the serum markers for hemostasis and thrombosis have been detected. A high index of suspicion is required by vascular surgeons for patients presenting with this novel virus. We present the case of a 51-year-old man with acute COVID-19 pneumonia who developed phlegmasia cerulea dolens despite chronic warfarin therapy and a supratherapeutic international normalized ratio.
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Affiliation(s)
- Tristen T Chun
- Department of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Juan Carlos Jimenez
- Department of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Joe L Pantoja
- Department of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - John M Moriarty
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Shanna Freeman
- Department of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif
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Abootalebi A, Salemi M, Heidari F, Azimi Meibody A. Phlegmasia Cerulea Dolens: A Rare Case Report. Adv Biomed Res 2020; 9:31. [PMID: 33072643 PMCID: PMC7532826 DOI: 10.4103/abr.abr_3_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/12/2020] [Accepted: 04/07/2020] [Indexed: 11/08/2022] Open
Abstract
Phlegmasia cerulea dolens is a severe form of deep venous thrombosis (DVT) characterized by severe venous outflow obstruction, marked limb swelling, pain, bluish discoloration, and even venous gangrene if the condition is untreated. In our case, 75-year-old woman, with general abdominal pain, which increases with eating and anorexia and 5 days of coldness and swelling of the left leg, was accepted. The patient had a history of Type II diabetes, ischemic heart disease, congestive heart failure, hyperlipidemic (HLP), hypertension, metastatic ovarian cancer, and previous DVT. She has undergone chemotherapy for the past 3 weeks due to ovarian cancers. Anticoagulation with intravenous administration of heparin and fluid resuscitation started immediately. The evidence of color Doppler sonography approved acute DVT in common femoral vein extending to the left external iliac. The patient did not consent for continuing the procedure in the hospital and succumbed to her illness on the 7th day after discharge.
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Affiliation(s)
- Alireza Abootalebi
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Salemi
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farhad Heidari
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azita Azimi Meibody
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Abstract
Phlegmasia cerulea dolens (PCD) is a rare presenting condition that carries a high mortality and morbidity risk. It is a cannot miss diagnosis with potentially deadly sequelae, and we highlight the importance of a thorough physical examination and initiation of empiric treatment to help prevent such.
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Affiliation(s)
- Davin Barnett
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
| | - John Casey
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
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44
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Saydam O, Serefli D. Outcomes of rheolytic thrombectomy in phlegmasia cerulea dolens. Vascular 2020; 29:280-289. [PMID: 32715971 DOI: 10.1177/1708538120943320] [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: 11/17/2022]
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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45
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Nickler M, Haubitz S, Méndez A, Gissler M, Stierli P, Kieback A. Phlegmasia cerulea dolens - an uncommon but alarming manifestation of deep vein thrombosis. VASA 2020; 49:422-426. [PMID: 32646321 DOI: 10.1024/0301-1526/a000894] [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: 11/19/2022]
Abstract
In phlegmasia cerulea dolens (PCD), immediate diagnosis and prompt treatment is crucial for limb salvage. Aggressive treatment options including venous intervention, thrombolysis and/or surgical thrombectomy should be considered. Due to the lack of data, the most appropriate intervention depends upon etiology of PCD, clinical presentation and patient's bleeding risk.
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Affiliation(s)
- Manuela Nickler
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sebastian Haubitz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland.,Medical University Department, Division of Infectiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Adriana Méndez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Martin Gissler
- Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Peter Stierli
- Surgical Department, Division of Vascular Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Arne Kieback
- Medical University Department, Division of Angiology, Kantonsspital Aarau, Aarau, Switzerland
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Management of Phlegmasia Cerulea Dolens with Percutaneous Mechanical Thrombectomy. Cardiovasc Intervent Radiol 2020; 43:1398-1401. [PMID: 32601719 DOI: 10.1007/s00270-020-02570-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/20/2020] [Indexed: 10/24/2022]
Abstract
Advanced cases of phlegmasia cerulea dolens (PCD) with absent pedal pulses, sensory/motor deficits, and/or venous gangrene likely require more rapid restoration of flow compared to cases without these factors to prevent progression and associated morbidity/mortality. We present a case of PCD with absent pedal pulses and sensory deficit managed successfully with emergent percutaneous mechanical thrombectomy using Inari ClotTriever (Inari Medical, Irvine, CA) with immediate clinical resolution, including restoration of pedal pulses ~ 45 min after thrombectomy. Percutaneous mechanical thrombectomy with the ClotTriever device has the ability to immediately restore venous flow reversing the pathophysiology of PCD in a short time period similar to surgical embolectomy and may be an alternative treatment strategy in patients with phlegmasia cerulea dolens of high severity.
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47
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Mühlberger D, Mumme A, Stücker M, Reich-Schupke S, Hummel T. Multimodal approach of venous recanalization in patients with a critical limb ischemia due to phlegmasia cerulea dolens: A case series of 17 patients in a single center. Phlebology 2020; 35:701-705. [PMID: 32580683 DOI: 10.1177/0268355520935744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Advanced phlegmasia cerulea dolens can be a hazardous complication of a deep vein thrombosis and rapid recanalization of the deep venous system is the most important factor. METHOD We describe the outcome of 17 patients with critical limb ischemia due to an advanced phlegmasia cerulea dolens. Venous thrombectomy was performed by a standardized operating procedure. RESULTS Venous recanalization was successful in all patients. An additional fasciotomy was not necessary. There were five patients with an underlying malignancy and eight patients with a simultaneous pulmonary embolism. We had one amputation of a forefoot and one death within 30 days representing a 30-day mortality and an amputation rate of 6%. CONCLUSIONS Early recanalization and recovery of the venous outflow is mandatory for success. A multimodal therapeutic approach of high urgency surgical thrombectomy in combination with endovenous strategies could be a successful treatment option for advanced phlegmasia cerulea dolens.
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Affiliation(s)
- Dominic Mühlberger
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Germany.,Vein Centre of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Germany
| | - Achim Mumme
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Germany.,Vein Centre of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Germany
| | - Markus Stücker
- Vein Centre of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Germany.,Department of Dermatology, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Germany
| | - Stefanie Reich-Schupke
- Vein Centre of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Germany.,Department of Dermatology, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Germany
| | - Thomas Hummel
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Ruhr University Bochum, Germany.,Vein Centre of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Germany
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48
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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: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [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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Mouawad NJ. Effective single-session percutaneous nonpharmacologic mechanical thrombectomy for phlegmasia cerulea dolens. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:212-215. [PMID: 32322779 PMCID: PMC7162958 DOI: 10.1016/j.jvscit.2020.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/08/2020] [Indexed: 11/19/2022]
Abstract
Phlegmasia cerulea dolens can be a potentially devastating complication of severe deep venous thrombosis leading to limb ischemia and tissue necrosis. This report describes a patient presenting with phlegmasia cerulea dolens of the right lower extremity. Because of the urgent nature of the condition, percutaneous nonpharmacologic mechanical thrombectomy in a single session was pursued. Extensive thrombus burden was removed from the patient, and vessel patency was restored after balloon venoplasty. The patient's symptoms rapidly resolved, and the targeted vessels remain patent at 3-month follow-up.
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Affiliation(s)
- Nicolas J. Mouawad
- Correspondence: Nicolas J. Mouawad, MD, MPH, MBA, FSVS, FRCS, FACS, RPVI, McLaren Bay Region, 1900 Columbus Ave, 4th Fl, South Tower, Bay City, MI 48708
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Söderman M, Grimm P. Phlegmasia cerulea dolens in a patient treated with carboplatin. BMJ Case Rep 2020; 13:13/4/e233760. [PMID: 32295798 DOI: 10.1136/bcr-2019-233760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare, fulminant, potentially lethal and often debilitating presentation of deep venous thrombosis (DVT). Mortality and amputations rates are high. We present a rare case of bilateral PCD in the lower extremities. A 67-year-old woman presented with newly diagnosed squamous cell cancer of unknown primary origin with lymph node metastases to the neck. The patient started curatively intended treatment, consisting of removal of one lymph node on the neck, radiotherapy with concomitant carboplatin and nimorazol. The patient developed bilateral DVT in the legs. Despite treatment with low-molecular-weight heparins, the patient developed thrombosis in the inferior vena cava and lungs. Due to developing painful discolouration and necrosis on the legs, the patient underwent acute and extensive surgery. PCD is a severe and potentially lethal form of DVT. There are several known risk factors for developing DVT, including active cancer and the use of chemotherapy.
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Affiliation(s)
- Martin Söderman
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark .,Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Peter Grimm
- Department of Oncology, Odense University Hospital, Odense, Denmark
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