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GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE
A Journal on Internal Medicine and Pharmacology
Indexed/Abstracted in: BIOSIS Previews, EMBASE, Scopus, Emerging Sources Citation Index
Gazzetta Medica Italiana Archivio per le Scienze Mediche 2012 August;171(4):517-21
Successful palliation of phlegmasia cerulea dolens using thrombolysis
Moghul M. R., Milkhu C. S., Hussain T.
Department of Vascular Surgery, Northwick Park Hospital, North-West London Hospitals NHS Trust, London, UK
There are 60,000 cases of deep vein thromboses annually in the UK. A small percentage of these progress to phlegmasia cerulea dolens; a limb and life-threatening condition causing excruciating pain and swelling. We present a case of a patient with phlegmasia cerulea dolens successfully palliated using direct thrombolysis via a venous catheter. As far as we are aware this is the first documented case of successful pain relief from PCD in a male patient with concurrent metastatic disease using catheter directed thrombolysis. The initial presentation was of sudden onset shortness of breath and limb swelling whilst on warfarin. Imaging showed progression of previous pulmonary emboli and bilateral deep vein thromboses. An inferior vena caval filter was inserted and warfarin continued however the leg swelling worsened unilaterally and further imaging showed progression of the thrombus; a clinical diagnosis of phlegmasia cerulea dolens was made. He was treated with continuous thrombolysis directed at the thrombus via a venous catheter for 5 days, and improved with reduced pain and increased venous patency. He later deteriorated and passed away due to his metastatic disease. Although a clinical diagnosis, contrast venography is the best diagnostic investigation for phlegmasia cerulea dolens. General management includes limb elevation, compression stockings and systemic anticoagulation however escalation with either surgical thrombectomy or thrombolysis is frequently required. We advocate usage of catheter-directed as a second line treatment, in preference to thrombectomy, which is preferred in venous gangrene or in patients with contraindications to thrombolysis, in line with other opinions.