Case Of Phlegmasia Cerulea Dolens Research Articles

Man with leg pain.

A 66-year-old-male with a history of type 2 diabetes and hypertension presented as a transfer for rapid progression of lower extremity pain, swelling, and blue-purple discoloration of the entire limb (Figure 1) with concern for a possible necrotizing infection. His symptoms began earlier in the day and progressed over just a few hours. He had no known thromboembolic risk factors. Initial vital signs were notable only for a heart rate of 115. Point-of-care ultrasound revealed extensive deep venous thrombosis burden confirmed by formal duplex sonography. The patient was admitted on a heparin infusion and underwent EKOSTM catheter directed tissue plasminogen therapy with stent placement. He was admitted for 5 days and successfully discharged on oral anticoagulation back to his baseline level of function. Phlegmasia cerulea dolens Phlegmasia cerulea dolens (PCD) is a rare ischemic complication of massive venous thromboembolism with high rates of morbidity and mortality. Patients present with limb edema, pain, and cyanosis that can quickly develop into compartment syndrome, limb ischemia, and venous gangrene with amputation and death rates as high as 50% and 40%, respectively.1 PCD tends to affect the iliofemoral segment of the lower extremities.2 Non-traumatic cases of PCD are most commonly associated with malignancy.3 The preferred imaging modality is Doppler ultrasound and use of point-of-care ultrasound by physicians can expedite treatment of PCD.4 Management includes limb elevation, intravenous fluids, and either systemic anticoagulation, catheter-directed thrombolysis, thrombectomy, or a combination of these definitive therapies.5

A rare case of phlegmasia cerulea dolens complicated with iliac vein perforation

A rare case of phlegmasia cerulea dolens complicated with iliac vein perforation

EP.TU.192Phlegmasia cerulea dolens associated with lung abscess

Abstract Introduction Phelgmasia cerulea dolens (PCD) is a rare limb and life-threatening condition caused by extensive of deep veins 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 death. Case presentation We present a rare case of phlegmasia cerulea dolens associated with lung abscess. A 40-year-old male with background history of right femoral vein thrombosis, cardiomyopathy with ejection fraction of only 10% presented with three days history of progressive swelling, pain and purple discoloration of right leg to the accident and emergency department at a district general hospital. He was treated with therapeutic low molecular weight heparin. He was found to have lung abscess 2 weeks after admission for which he was treated with broad spectrum intra venous antibiotics. In view of his poor ejection fraction, he was treated without any surgical intervention for PCD. Patient succumbed after 3 months of presentation. PCD is a rare vascular emergency condition if not recognized early and treated aggressively may lead to high morbidity and mortality. Conclusion Phlegmasia cerulea dolens is an acute limb and life-threatening condition. Early diagnosis and aggressive intervention with thrombolysis and thrombectomy is necessary to prevent morbidity and mortality.

PHLEGMASIA CERULEA DOLENS: AN ATYPICAL COVID-19 PRESENTATION

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The worldwide pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused numerous deaths worldwide, most directly due to resultant ARDS and respiratory failure. Physicians have seen an increased incidence of venous thromboembolic events (VTE) in COVID-19 patients postulated due to a pro-inflammatory state caused by the virus, with a resultant increase in the frequency of micro thrombotic events [1]. We present the case of a patient with severe Phlegmasia cerulea dolens (PCD) in the setting of asymptomatic COVID-19 pneumonia. CASE PRESENTATION: A 61 yo African American male with no significant past medical history presented with left leg swelling. Arterial and venous doppler ultrasound revealed an extensive thrombus throughout the left femoral and popliteal veins, with occlusion of arterial flow at the distal posterior tibial and peroneal arteries consistent with compartment syndrome and diagnosis of PCD. CT scan of the chest resulted in a finding of a large left main pulmonary artery pulmonary embolism with bilateral patchy ground-glass opacities suggestive of COVID-19 pneumonia, which was confirmed positive by rapid nasopharyngeal PCR per our admission protocol despite the absence of fever, cough, shortness of breath or exposure. He was started emergently on anticoagulation therapy, intubated prophylactically, and taken to the operating room for emergent fasciotomy. His ICU course was complicated by worsening ventilator support, acute respiratory distress syndrome, worsening kidney injury, septic shock, and persistent bleeding from his wound requiring multiple transfusions. Due to nonviability and poor healing, the extremity was amputated, with noted systemic improvement in the ensuring days. He was extubated, downgraded out of the ICU, but this improvement was short-lived. His respiratory status drastically deteriorated, requiring re-intubation for hypoxia with recurrence of septic shock due to E.coli bacteremia as well as severe bleeding from the stump site. His status-declined with multiorgan failure despite aggressive resuscitation, broad-spectrum antibiotics, blood transfusion, pressor requirement, and continuous renal replacement therapy. The decision was made by the family to withdraw life support, and the patient expired. DISCUSSION: An increased presence of coagulopathy and VTEs has been seen in COVID-19 patients in both the ICU and medical floors [2].To date, the exact mechanism that leads to thromboembolic disease has yet to be determined but is thought to be due to the familiar combination of Virchow’s triad: endothelial injury, blood stasis, and a hypercoagulable state [2-3]. CONCLUSIONS: In our case, the patient continued to deteriorate despite anticoagulation for his VTE. While not all patients with COVID-19 develop VTEs, it is important to be aware of the heightened risk for micro- and macro-thrombotic events in patients with SARS-CoV-2. Reference #1: Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19 [published online ahead of print, 2020 May 5]. J Thromb Haemost. 2020;10.1111/jth.14888. doi:10.1111/jth.14888 Reference #2: Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens [published online ahead of print, 2020 May 15]. Am J Emerg Med. 2020;10.1016/j.ajem.2020.05.022. doi:10.1016/j.ajem.2020.05.022 Reference #3: Helms J. High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020 doi: 10.1007/s00134-020-06062-x DISCLOSURES: No relevant relationships by Riad Akkari, source=Web Response No relevant relationships by Brad Schwartz, source=Web Response

A RARE CASE OF PHLEGMASIA CERULEA DOLENS SECONDARY TO MAY THURNER SYNDROME

In individuals presenting with leg pain & discoloration, Phlegmasia cerulea dolens (PCD) must be ruled out as it is a limb & life-threatening emergency. We present a case of PCD in a patient with May Thurner Syndrome (MTS). 83-year-old female with hypertension & type 2 diabetes presented with one

Phlegmasia cerulea dolens following internal hemipelvectomy: Case report and literature review

Phlegmasia cerulea dolens (PCD) results from near complete venous thrombosis and occlusion in an extremity resulting in pain, cyanosis, and edema and potentially death. While PCD can result from a variety of mechanisms including trauma, iatrogenic instrumentation, the majority of cases occur in the setting of malignancy. PCD is often managed medically with anticoagulation. However, in certain circumstances, surgical intervention may be warranted. Here, we present a unique case of phlegmasia cerulea dolens occurring following an internal hemipelvectomy requiring emergent surgical intervention to salvage life and limb. A review of the literature regarding diagnosis and treatment is also presented.

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia: A Case Study.

Introduction:Phlegmasia cerulea dolens (PCD) is a rare pathology with a very high morbidity and mortality rate, which usually occurs in the lower limb. There is very little literature available to aid management.Case Report:We present a case of upper limb PCD in a 67-year-old female secondary to heparin-induced thrombocytopenia caused by warfarin bridging. She presented to the orthopedic team with upper limb compartment syndrome from a bleed around a peripherally inserted central catheter, for which she was urgently taken to the theater for fasciotomies. Postoperatively, the patient’s platelets dropped and the upper limb pain and swelling continued; after conservative management and anticoagulation failed the patient had an upper limb amputation of her right arm.Conclusion:With limited guidelines and management options restricted by the large fasciotomy wounds, we believe amputation was the patients’ best option.

La phlébite bleue

Herein we report a case of phlegmasia cerulea dolens, a form of venous thrombosis complicated by arterial ischaemia.A 69-year-old man presented a bilateral trophic condition of the lower limbs that had appeared 3 weeks earlier. The patient had a history of metastatic urothelial bladder carcinoma and arteritis. Clinical examination revealed right leg ulcers with massive bilateral oedema of the lower limbs, cyanosis and local ischaemia. Doppler ultrasound revealed bilateral and proximal deep vein thrombosis (sural and superficial femoral veins of the right leg; sural and iliac veins of the left leg) without any distal arterial flow. We concluded on a diagnosis of bilateral phlegmasia cerulea dolens.Phlegmasia cerulea dolens is a particular type of deep venous thrombosis in which a proximal venous thrombus is combined with arterial ischaemic signs due to brutal and massive oedema and slowing down of arterial flow. In most cases, the lower limbs are involved, with malignancy being the most common cause. It should be suspected in the presence of the classical triad of "pain, oedema and cyanosis", with confirmation by Doppler ultrasound. There is no general consensus regarding standard management. Traditionally, systemic anticoagulation has been the mainstay of treatment for this condition. Endovascular surgery may be a possibility in some cases. Prompt diagnosis and rapid treatment initiation are paramount in order to improve the prognosis of this severe condition with ominous prospects.

Phlegmasia Cerulea Dolens after Coronary Artery Bypass Surgery: What Should We Know

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

Flegmasia cerúlea dolens em paciente com lúpus eritematoso sistêmico no puerpério remoto

Vascular manifestations are not rare in systemic lupus erythematosus and, in most cases, are associated with antiphospholipid antibodies. Phlegmasia cerulea dolens is an unusual and severe complication of deep venous thrombosis of the lower limbs, which has a high mortality rate. In the literature, only two cases of phlegmasia cerulea dolens associated with primary antiphospholipid syndrome have been reported, but none associated with systemic lupus erythematosus. We report one case of phlegmasia cerulea dolens with rapid evolution to death in a patient with systemic lupus erythematosus in the remote postpartum period.

Phlegmasia cerulea dolens in a patient with chronic myelogenous leukemia—a case report

Phlegmasia cerulea dolens (PCD), a rare condition caused by deep venous thrombosis of the extremities and characterized by sudden massive edema, severe intractable pain, and purple ecchymoses, may result in arterial and venous compromise, amputation, and death. The causes of PCD vary and there is no consensus regarding optimal treatment. We describe what we believe is the first reported case of PCD in a patient with chronic myelogenous leukemia. The condition was treated successfully with thromboembolectomy performed after temporary placement of an inferior vena cava filter to prevent intraoperative pulmonary embolism. The thromboembolectomy specimen consisted of leukemic tumor emboli.

Simultaneous Arterial and Venous Ultrasound-Assisted Thrombolysis for Phlegmasia Cerulea Dolens

Phlegmasia cerulea dolens is a rare condition in which an extensive deep venous thrombus can partially or completely occlude venous outflow from the affected extremity. Clinical presentation is typically characterized by extremity edema, cyanosis, and pain. This condition is associated with a high rate of extremity amputation and mortality. Although numerous therapies have been described, there is no generalized treatment consensus and less invasive forms of therapy continue to evolve. We report a case of phlegmasia cerulea dolens in a patient who presented with concomitant arterial and venous thrombosis of the affected extremity. The patient's condition was successfully treated using combined ultrasound-assisted intra-arterial and intravenous catheter-directed thrombolysis.

A Case of Phlegmasia Cerulea Dolens as a Complication Caused by Placement of Inferior Vena Cava Filter

Inferior vena cava filters are increasingly being used as an alternative to anticoagulation therapy for the prevention of pulmonary embolism. However, using an Inferior vena cava filter may result in clinically significant complications. Phlegmasia cerulea dolens is a rare disease that presents with acute complete venous occlusion due to extensive thrombosis in the lower extremity. It is characterized by intense pain, edema, decreased pulses and a cyanotic extremity. We report here on a case of phlegmasia cerulea dolens that was accompanied with disseminated intravascular coagulation (DIC) as a complication of the placement of an inferior vena cava filter in a patient who had been previously diagnosed with pulmonary embolism, and the patient had recently developed a cerebral hemorrhage due to a traffic accident. (Tuberc Respir Dis 2008;65:225-229)

Successful catheter-directed venous thrombolysis in phlegmasia cerulea dolens

Background Phlegmasia cerulea dolens is an extremely rare condition caused by complete venous occlusion and often results in tissue necrosis, limb amputation, or death. Treatment options include systemic anticoagulation, systemic thrombolytic therapy, fasciotomy, or surgical thrombectomy. Rare case reports have described the use of catheter-directed thrombolysis in the treatment of this condition. Prompt diagnosis and treatment initiation are important to prevent gangrene, amputation, and ultimately death. Case We report two unusual cases of phlegmasia cerulea dolens that presented in patients with aggressive gynecologic malignancies and who were successfully treated with catheter-directed thrombolytic therapy. Conclusion To maximize the opportunity for limb salvage, catheter-directed venous thrombolytic therapy should be considered in the treatment of phlegmasia cerulea dolens that presents in the gynecologic oncology patient.

Catheter-Directed Thrombolysis in the Treatment of Phlegmasia Cerulea Dolens

Phlegmasia cerulea dolens is a potentially devastating complication of extensive deep venous thrombosis for which there is currently no consensus for treatment. Heparin anticoagulation, surgical thrombectomy, thrombolytic therapy, fasciotomy, and amputation have each been advocated. We present two cases of phlegmasia cerulea dolens successfully treated with catheter-directed venous thrombolytic therapy.

Complications From Heparin-induced Thrombocytopenia in Patients Undergoing Cardiopulmonary Bypass

The purpose of this study was to evaluate retrospectively the incidence and severity of heparin-induced thrombocytopenia (HIT)-related complications in patients undergoing cardiopulmonary bypass. We reviewed the records of 1,500 consecutive patients who underwent cardiopulmonary bypass between August 1987 and December 1991 at Thomas Jefferson University Hospital. During this period of time, there were 1,155 coronary artery bypass graft operations (77 percent); 225 valve replacements and repairs, or both (15 percent); 60 combination coronary artery bypass graft or valve operations, or both (4 percent); and 60 miscellaneous procedures (4 percent). Although not all patients with postoperative complications were tested for the HIT antibody, 11 patients (0.75 percent) were diagnosed with HIT. There were 17 complications in these 5 men and 6 women including 6 cases of ischemic limbs which required amputation, 4 strokes, 2 instances of saphenous vein graft occlusion with resulting myocardial infarction, 2 cases of pulmonary emboli, 1 case of phlegmasia cerulea dolens, and 2 deaths. The complications occurred an average of 3.6 days postoperatively, with a range of occurrence of 1 to 11 days postoperatively. The mean nadir platelet count at the time of recognition was 123,000/mm3 (range 32,000 to 193,000/mm3) with 9 of 11 patients (81.8 percent) having counts greater than 100,000/mm3. There was, however, a mean percent decrease in the platelet count of 50 percent (range, 31 to 75 percent) from the time of first exposure to heparin to the time of recognition of HIT. In our patients, HIT was not related to the type, duration of treatment with or amount of heparin, or to pretreatment with aspirin.

A case of phlegmasia cerulea dolens treated successfully with intravenous and intraarterial transcatheter thrombolysis: Frank J. Criado, MD, Maryland Vascular Institute, Baltimore, Md.

A case of phlegmasia cerulea dolens treated successfully with intravenous and intraarterial transcatheter thrombolysis: Frank J. Criado, MD, Maryland Vascular Institute, Baltimore, Md.

Evaluation of Phlegmasia Cerulea Dolens Using Radionuclide Venography

Phlegmasia cerulea dolens (PCD) is characterized by the presence of massive venous occlusion of the veins in an extremity, leading to ischemia and sometimes gangrene. We report a case of phlegmasia cerulea dolens that was evaluated by radionuclide venography. We report both this case and information regarding phlegmasia and therapy of PCD to promote awareness of this disorder among radiologists and nuclear medicine physicians who perform radionuclide venograms.

Phlegmasia cerulea dolens: therapeutic considerations.

Phlegmasia cerulea dolens (PCD) is a rare venous disorder that continues to be a major therapeutic challenge. We reviewed 16 cases of PCD treated during the past 15 years; 11 of the patients were male, and the average age of all the patients was 59 years. Malignant disease was the most common underlying condition (seven patients). Venous gangrene (VG) was present in seven extremities. Three treatment methods were used alone or in combination--intravenous heparin, venous thrombectomy, and thrombolytic therapy. Heparin was used initially in 13 patients; it yielded a successful result in seven (53%) patients, none of whom had VG. Venous thrombectomy was done in six patients; in three it was the primary procedure, in two it followed failure of heparin, and in one it followed failure of both heparin and thrombolytic therapy. Venous thrombectomy was successful in three (50%) patients, one of whom had early VG. Thrombolytic therapy was used on one occasion in conjunction with both heparin and venous thrombectomy, without benefit. Five patients died, all with VG, three after heparin only, one after heparin and venous thrombectomy, and one after all three treatment methods. Review of the 38 cases reported in the recent literature shows comparable results. These data suggest that nongangrenous forms of PCD respond well to systemic anticoagulation. Combination therapy using venous thrombectomy and heparin is indicated for severe ischemia, early VG, or failure of PCD to improve after six to 12 hours of heparin therapy. Phlegmasia cerulea dolens with VG is the lethal form of the entity and responds poorly to established therapy. Future therapeutic trials need to consider aggressive use of thrombolysis with or without thrombectomy.