Endoluminal Recanalization in a Patient with Phlegmasia Cerulea Dolens Using a Multimodality Approach

Abstract

Phlegmasia cerulea dolens is a limb-threatening form of deep venous thrombosis and should be treated aggressively. The authors report a patient who presented with iliocaval and femoral deep venous thrombosis and posed an additional therapeutic challenge based on a recent history of heparin-induced thrombocytopenia. Catheter-directed pharmacologic thrombolysis and balloon venoplasty were applied in treatment. The direct thrombin inhibitor argatroban was used in place of heparin for concurrent anticoagulation. This multimodality endovascular approach (chemical and mechanical interventions) was successful in relieving the venous occlusion and salvaging the limb, while maintaining appropriate treatment for heparin-induced thrombocytopenia.

Use of argatroban and catheter-directed thrombolysis with alteplase in an oncology patient with heparin-induced thrombocytopenia with thrombosis

“…To date, only three previous case reports have described the use of direct thrombin inhibitors in combination with alteplase during CDT in patients with HITT. [16][17][18] In the first case report, Lin and colleagues 16 described a 52-year-old woman with a history of ovarian cancer who received treatment for bilateral calf DVT and PE with a low-molecular-weight heparin product and an inferior vena cava (IVC) filter. She subsequently developed HITT with complete occlusion of the right femoral and iliac veins approximately three weeks after a total abdominal hysterectomy and bilateral salpingo-oophorectomy.…”

“…The clinical literature describing the use and management of alternative, nonheparin anticoagulants with alteplase during CDT is still very limited. [16][17][18] Here we report the case of an oncology patient with HITT in whom argatroban and CDT with alteplase were used.…”

A multimodal therapeutic approach to phlegmasia cerulea dolens in a pediatric patient

“…Patients should first receive treatment with systemic anticoagulation, leg elevation, compression stockings, and fluid resuscitation. 11 Surgical thrombectomy had historically been the primary therapy for patients who were refractory to systemic therapy; however, perioperative recurrence and damage of venous valves often occur. Thrombolytic therapy has evolved from systemic administration to catheterdirected delivery.…”

Efficacy of histotripsy combined with rt-PAin vitro

“…Acute thrombus formation can occur in hypercoagulable patients (Patel et al 2000). The most severe acute consequence of DVT is phlegmasia cerulea dolens, a critical obstruction of iliofemoral venous return, which is prevalent in 4% of DVT patients (Lin et al 2005, Oguzkurt et al 2011). Clinical presentation of phlegmasia cerulea dolens requires amputation in 15% of patients due to venous gangrene (Patel et al 1998), and has a 25% mortality rate (Lin et al 2005, Hood et al 1993).…”

“…The most severe acute consequence of DVT is phlegmasia cerulea dolens, a critical obstruction of iliofemoral venous return, which is prevalent in 4% of DVT patients (Lin et al 2005, Oguzkurt et al 2011). Clinical presentation of phlegmasia cerulea dolens requires amputation in 15% of patients due to venous gangrene (Patel et al 1998), and has a 25% mortality rate (Lin et al 2005, Hood et al 1993). For critical venous obstructions, catheter-directed thrombolytic drugs (Augustinos 2004) are the frontline therapy for recanalization (Kalagher and Kane 2014).…”