Case report of simultaneous phlegmasia cerulea dolens and acute limb ischemia

Abstract

Introduction: Phlegmasia cerulea dolens (PCD) is a rare, life- and limb-threatening condition of acute massive deep vein thrombosis (DVT) that requires emergent therapeutic intervention. While endovascular therapy is the preferred treatment approach, we describe a case where surgical embolectomy is an alternative approach in specific scenarios. In our case, we presented a patient with simultaneous PCD and acute limb ischemia (ALI).

Case report: A patient presented with haematuria, abdominal pain, cyanotic changes in the limb, and sensory/motor deficits in the right lower limb. Imaging tests revealed thromboembolic occlusion of both the arterial and venous systems and a bleeding tumour in the pelvic region. Due to the rapid progression of symptoms, macroscopic haematuria with anaemia, renal failure, and the necessity for intervention in both the arterial and venous systems, we performed a successful simultaneous surgical embolectomy of the arterial and venous systems right lower limb, resulting in prompt symptom resolution.

Discussion: Phlegmasia cerulea dolens is a rare manifestation of massive iliofemoral deep vein thrombosis. Its pathophysiology can indirectly compromise arterial patency. Treatment options include endovascular therapy - catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT) or surgical intervention. These options carry risks, including damage to the venous endothelium or periprocedural pulmonary embolism. This case report demonstrates a situation where surgical intervention was a viable option. We presented a more endothelium-sparing surgical approach using a sterile compression bandage during embolectomy.

In conclusion: To date, there are no established guidelines from professional societies regarding the treatment of PCD. The authors emphasize the need for an individualized approach to patients with PCD. They also highlight the importance of access to comprehensive treatment, including both endovascular and surgical methods.

Methods: work has been reported in line with SCARE criteria.

Keywords: Acute limb ischemia; Case report; Catheter-directed thrombolysis; Embolectomy; Pelvic tumour; Phlegmasia alba dolens; Phlegmasia cerulea dolens.