A Strategy for Achieving Early Reperfusion and Complete Clot Removal Using Endovascular Techniques for Management of Phlegmasia Cerulea Dolens

Abstract

Phlegmasia cerulea dolens occurs when occluding caval or lower extremity deep venous thrombosis produces venous swelling sufficient to occlude arterial inflow. Ideal treatment should reduce swelling quickly, restore arterial perfusion, and eliminate all venous thrombus, preserving valvular function. Treatment options include any combination of open balloon thrombectomy, catheter-directed thrombolysis (CDT), and mechanical or aspiration thrombectomy. Open thrombectomy can be performed expeditiously but may leave thrombus or damage valves. Endovascular techniques may require time to resolve swelling and to restore perfusion but allow better clot removal, preserving valvular function. We describe a strategy of a combination of endovascular techniques that provide both rapid improvement and complete clot lysis. A 54-year-old woman with stage IV lung cancer developed bilateral deep venous thrombosis and pulmonary emboli. She was treated with intravenous tissue plasminogen activator, inferior vena cava filter, and oral anticoagulation. She presented 2 months later with worsening and painful swollen lower extremities. Physical examination showed bilateral swelling, mottling, and no palpable pulses. Doppler signals were present in both dorsalis pedis arteries. Venography showed occluding thrombus from the inferior vena cava filter to the popliteal veins bilaterally (Fig 1, A). Arteriography showed slow flow distal to the midcalf. AngioJet Power Pulse (Boston Scientific, Natick, Mass) pharmacomechanical thrombectomy (PMT) with tissue plasminogen activator was used to re-establish iliac vein outflow immediately. CDT using two infusion catheters and a bilateral up-and-over technique was performed during 72 hours with daily venography. We used a combination of early iliac clot debulking with caval protection, PMT, and up-and-over thrombolysis infusion catheters to achieve early improvement in perfusion followed by complete clot resolution (Fig 1, B). Phlegmasia cerulea dolens requires aggressive treatment. Early restoration of arterial perfusion is essential. Complete clot removal with maintenance of valvular competence may prevent post-thrombotic syndrome. Initial PMT combined with ongoing CDT can provide these outcomes. Up-and-over infusion catheters are a useful alternative to prograde popliteal access, reducing the likelihood of access site complications from compression in the popliteal veins after treatment.