전체메뉴
Article Search

VSI Vascular Specialist International

Open Access

pISSN 2288-7970
eISSN 2288-7989
QR Code QR Code

Case Report

Related articles in VSI

More Related Articles

Article

Case Report

Vascular Specialist International 2016; 32(4): 201-204

Published online December 31, 2016 https://doi.org/10.5758/vsi.2016.32.4.201

Copyright © The Korean Society for Vascular Surgery.

Surgical Thrombectomy for Phlegmasia Cerulea Dolens

Shin-Seok Yang, and Woo-Sung Yun

Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea

Correspondence to:Woo-Sung Yun, Division of Transplantation and Vascular Surgery, Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea, Tel: 82-53-620-3580, Fax: 82-53-624-1213, E-mail: wsyun@me.com, wsyun@ynu.ac.kr

Received: August 16, 2016; Revised: October 10, 2016; Accepted: October 13, 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Phlegmasia cerulea dolens (PCD) is a medical emergency that can lead to venous gangrene of the lower extremity. Early diagnosis and prompt treatment is crucial for limb salvage. There are two treatment options (endovascular or surgical). In the endovascular era, catheter-directed thrombolysis is the treatment of choice to achieve venous outflow. However, surgical thrombectomy is indicated in certain cases. The authors report successful surgical thrombectomy in a 75-year-old man with PCD and review the treatment of PCD.

Keywords: Venous thrombosis, Thrombectomy, Gangrene

INTRODUCTION

Massive ilio-femoral deep vein thrombosis (DVT) may cause phlegmasia cerulea dolens (PCD, blue swollen leg). PCD is a rare form of DVT and venous gangrene may occur as arterial inflow becomes obstructed because of extreme levels of venous hypertension [1]. The primary treatment goals in PCD include restoration of venous outflow, prevention of thrombus formation and preservation of collateral circulation [2]. There are no therapeutic algorithms due to its rarity, but for limb salvage, emergent venous thrombectomy or thrombolytic therapy is necessary [3]. Here, we report a case of PCD treated successful by surgical thrombectomy.

CASE

A 75-year-old male presented at our emergency department with painful swelling of his left leg for 12 hours without prior trauma history (Fig. 1A). He also complained of numbness and weakness of the left lower leg and foot. His medical history was notable for hypertension and hyperlipidemia. On physical examination, the entire leg showed purplish discolorization and left femoral and dorsalis pedis artery pulses were detectable by hand-held Doppler. Duplex ultrasound (DUS) revealed left ilio-femoro-popliteal DVT (Fig. 2). Intravenous heparin was immediately administered and an emergent venous thrombectomy was performed under local anesthesia (Fig. 3), which provided pain relief. The next day, the left leg color was normalized (Fig. 1B) and motor and sensory defects were fully recovered. Anticoagulation therapy was prescribed for 6 months and follow-up computed tomography (CT) at 6 months revealed no residual thrombus (Fig. 4).

DISCUSSION

The pathophysiology of PCD involves extensive venous obstruction leading to increased interstitial tissue pressure, arrest of capillary blood flow, tissue ischemia and ultimately gangrene, which can cause limb loss and even death. Reported mortality rates range from 20% to 41% and reported amputation rates among survivors range from 12% to 50% [4].

Prompt diagnosis and adequate treatment is crucial for avoiding limb loss and death. The first line diagnostic modality for DVT is DUS, which can rule out the possibility of arterial occlusion. When a diagnosis of PCD is made, heparin should be administered and thrombus removal conducted as soon as possible to restore venous outflow. There are two primary options for thrombus removal, that is, venous thrombectomy or endovascular methods, such as catheter-directed thrombolysis, mechanical thrombectomy, or pharmacomechanical thrombectomy [3]. Treatment selection depends largely on the extent of ischemia as determined by the clinical categories of acute limb ischemia (ALI) [5]. Endovascular treatment is the initial treatment of choice for class I or class IIa ALI, and surgical thrombectomy is indicated for a profoundly ischemic limb (class IIb ALI) [6]. Barham and Shah [7] reported a case of PCD that progressed to venous gangrene despite continued intravenous anticoagulation therapy and mechanical thrombectomy. In this patient, we adopted surgical thrombectomy to achieve venous outflow more quickly because he showed sensory loss and muscle weakness (class IIb ALI). In addition, surgical thrombectomy can also be considered when thrombolytic therapy fails or thrombolytic therapy is contraindicated. However, if profound irreversible ischemic change is apparent in the affected limb, primary amputation should be performed.

In conclusion, PCD is a rare fulminant condition of DVT and surgical venous thrombectomy is a useful treatment option for limb salvage.

Fig 1.

Figure 1.The patient’s lower extremities at presentation (A) and postoperative day 1 (B).
Vascular Specialist International 2016; 32: 201-204https://doi.org/10.5758/vsi.2016.32.4.201

Fig 2.

Figure 2.Duplex ultrasound revealed thrombotic occlusion of the left external iliac vein (A), common femoral vein (B), femoral vein (C), and popliteal vein (D).
Vascular Specialist International 2016; 32: 201-204https://doi.org/10.5758/vsi.2016.32.4.201

Fig 3.

Figure 3.Venous thrombectomy was done with 4 Fr Fogarty catheter.
Vascular Specialist International 2016; 32: 201-204https://doi.org/10.5758/vsi.2016.32.4.201

Fig 4.

Figure 4.(A–E) Follow-up computed tomography (CT) showed no residual thrombus of the left ilio-femoro-popliteal vein.
Vascular Specialist International 2016; 32: 201-204https://doi.org/10.5758/vsi.2016.32.4.201

References

  1. Wakefield, TW (2009). Treatment algorithm for acute deep venous thrombosis: current guidelines. Handbook of venous disorders, Gloviczki, P, ed. London: Hodder Arnold, pp. 265-276
  2. Tung, CS, Soliman, PT, Wallace, MJ, Wolf, JK, and Bodurka, DC (2007). Successful catheter-directed venous thrombolysis in phlegmasia cerulea dolens. Gynecol Oncol. 107, 140-142.
    Pubmed CrossRef
  3. Chinsakchai, K, Ten Duis, K, Moll, FL, and de Borst, GJ (2011). Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 45, 5-14.
    Pubmed CrossRef
  4. Patel, NH, Plorde, JJ, and Meissner, M (1998). Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens. Ann Vasc Surg. 12, 471-475.
    Pubmed CrossRef
  5. Rutherford, RB, Baker, JD, Ernst, C, Johnston, KW, Porter, JM, and Ahn, S (1997). Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 26, 517-538.
    Pubmed CrossRef
  6. Norgren, L, Hiatt, WR, Dormandy, JA, Nehler, MR, Harris, KA, and Fowkes, FG (2007). Inter-society consensus for the management of peripheral arterial disease (TASC II).. J Vasc Surg. 45, S5-S67.
    CrossRef
  7. Barham, K, and Shah, T (2007). Images in clinical medicine. Phlegmasia cerulea dolens. N Engl J Med. 356, e3.
    Pubmed CrossRef