Upper Extremity Compartment Syndrome in the Setting of Deep Venous Thrombosis and Phlegmasia Cerulea Dolens: Case Report

Bedri, Mazen I.; Khosravi, Abtin H.; Lifchez, Scott D.

doi:10.1016/j.jhsa.2009.08.003

Cited by 15 publications

(14 citation statements)

References 33 publications

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“…Progressively, arterial flow becomes more compromised, leading to loss of peripheral pulses, then peripheral limb ischemia and gangrene. Case reports have shown that patients can accumulate up to 6 -10 L of fluid within their lower limb tissue within 5 -10 days [13]. Our patient's worsening lower leg pain, pallor and edema suggest that venous hypertension and extravasation of fluid from his lower venous system occur, resulting in profoundly diminished preload and his seemingly refractory hypovolemic shock.…”

Section: Discussionmentioning

confidence: 73%

Acute Refractory Hypotension 24 Hours Post-Inferior Vena Cave Filter Insertion Complicated by Early Phlegmasia Cerulea Dolens

et al. 2015

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We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refractory hypotension 24 hours postinferior vena cave filter (IVCF) insertion for a new finding of pulmonary embolism (PE) and ongoing melena stool. After 18 hours of aggressive 20 L intravenous fluid resuscitation in the ICU followed by vasopressors and intravenous antibiotics, a point-of-care echocardiography did not reveal right ventricular strain and a non-contrast CT scan of the abdominal and pelvis was reported as not remarkable. But his lower limbs became progressively edematous and swollen while his upper limb maintained its normal circumference. At 24 hours post-ICU admission, his lower limbs had worsened with severe pain and pallor. The compartmental pressure measurements were in the high normal ranges. At morning rounds, the complete occlusion of the IVCF causing severe hypovolemic shock was considered and re-review of the non-contrast CT abdomen and pelvis showed complete collapsed IVC above the IVCF. The IVC below the IVCF was distended, as were the common and external iliac veins bilaterally concerning for extensive venous thrombosis and early phlegmasia cerulea dolens (PCD). The patient was treated with local catheterdirected thrombolysis with thrombus maceration and aspiration followed by localized direct tissue plasminogen activator (tPA) infusion and systemic heparin infusion. The patient's refractory hypotension resolved quickly and had surgery to remove his gastric tumor 8 days post-IVCF insertion. The placement of IVCF in a patient with known malignancy can greatly increase the risk for additional thrombus formation. But in our patient the speed is unprecedented, in which complete vena cava thrombosis (VCT) occurred at the site of the IVCF and below and its mechanism of causing refractory hypotension is rare. The consideration of PCD in a patient with refractory hypovolemic shock post-IVCF insertion followed by aggressive fluid resuscitation and worsening lower limb pain and discoloration remains a rare but important differential diagnosis.

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Section: Discussionmentioning

confidence: 73%

Acute Refractory Hypotension 24 Hours Post-Inferior Vena Cave Filter Insertion Complicated by Early Phlegmasia Cerulea Dolens

et al. 2015

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“…1,7 In phlegmasia alba dolens, the major deep veins are involved with sparing of the collateral veins. Once the venous outflow completely occludes, the hydrostatic pressure at the venous end of the capillary rises to exceed colloid oncotic pressure and interstitial edema develops, which can be as much as 6--10 liters within days.…”

Section: Discussionmentioning

confidence: 99%

“…3 Twenty-forty percent of patients with phlegmasia cerulea dolens have an underlying malignancy. 1,7 Other triggering factors include a hypercoagulable syndrome, surgery, trauma, gastroenteritis, heart failure, mitral valve stenosis, vena caval filter insertion, and even pregnancy. However, 10% of patients with phlegmasia have no obvious cause.…”

Section: Discussionmentioning

confidence: 99%

“…7 Fasciotomy is an additional treatment option that has been used in a few patients in conjunction with thrombolysis or thrombectomy. 1,11 The results were mixed, but according to Perkins et al 7 it may reduce compartmental pressures. Prolonged wound healing and risk of infection have prevented the technique from being incorporated routinely in the treatment of phlegmasia cerulea dolens or venous gangrene.…”

Section: Discussionmentioning

confidence: 99%

“…Prolonged wound healing and risk of infection have prevented the technique from being incorporated routinely in the treatment of phlegmasia cerulea dolens or venous gangrene. 7 Recently, Bedri et al 1 reported a case that required both thrombolysis and fasciotomy in a patient with stage IV nonsmall-cell lung cancer and were able to achieve wound healing by primary suture and split-thickness skin grafting.…”

Section: Discussionmentioning

confidence: 99%

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