Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia

Authors

  • Fábio Pais Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Anita Quintas Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Isabel Vieira Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Joana Catarino Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-1559-5479
  • Ricardo Correia Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-0509-3715
  • Rita Bento Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Rita Garcia Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-5135-0196
  • Joana Cardoso Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal https://orcid.org/0000-0002-8908-2318
  • Tiago Ribeiro Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Rita Ferreira Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
  • Gonçalo Alves Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
  • Frederico Bastos Gonçalves Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
  • Maria Emília Ferreira Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal

DOI:

https://doi.org/10.48750/acv.358

Keywords:

Venus thrombosis, deep venous thrombosis, phlegmasia cerulea, endovascular catheter-directed thrombolysis, Cockett Syndrome, thrombectomy

Abstract

INTRODUCTION: Phlegmasia cerulea (PC) is a severe form of deep vein thrombosis. In the setting of massive venous thrombosis and severe ischemia, catheter-directed thrombolysis (CDT) or trombectomy is mandatory. We report three cases of women with PC managed with venous thrombectomy after failure of CDT.

CASE REPORTS: 1: 20 years-old, with recent intake of oral contraceptive, referred with acute onset of limb swelling, pain and a cold left lower extremity associated with foot pallor, paresthesia and numbness. Doppler ultrasound revealed occlusive thrombosis of the entire deep venous system and the great saphenous vein (GSV). Anticoagulation (AC) and CDT were started. However due to increasing levels of transaminases, creatine kinase and myoglobin, CTD was stopped and venous thrombectomy was proposed. A retrievable inferior vena cava filter (IVC) was implanted and venous surgical trombectomy. The completion venography showed a Cockett compression that was treated with stenting of the left iliac vein. Thrombophilia tests were positive for anticardiolipin antibodies an hyperhomocysteinemia. At 3-years follow-up, the patient is asymptomatic and under AC. The 3-year Doppler showed normal patency for the iliac stent and a mild femoropopliteal vein insuffiency.

2: 19 year-old, taking oral  contraceptives, with acute onset of PCD with acute thrombus in the left iliac, femoral, popliteal veins. CDT was started at admittance but stopped after two days because of very low values of serum fibrinogen and persistence of occlusive thrombus in the iliac vein. A retrievable IVC filter was placed and the thrombus removed with surgical thrombectomy. Phlebography showed no significant residual thrombus and no signs of compression were present. At 1 month follow-up, the patient presented without leg edema or venous claudication symptoms. Thrombophilia testing is awaited.

3: 54 year-old who presented with low back pain, worsening left leg pain and swelling with a cyanosed and colder foot. At doppler ultrasound there were monophasic arterial flow in the left leg. After exclusion of arterial embolism, the first therapeutic approach was CDT, but it was also stopped due to very low fibrinogen levels and an ineffective thrombus lysis in venography controls. After implantation of a retrievable IVC, surgical thrombectomy via femoral vein was performed, with successful thrombus removal. Venography showed Cockett syndrome and a stent was implanted. At 6 months the patient remained without major symptoms, and Doppler confirmed stent patency with non residual obstruction or venous insufficiency.

CONCLUSION: Awareness and timely diagnosis of phlegmasia cerulea is necessary to ensure prompt intervention to prevent loss of limb. When CDT is not effective, surgical thrombectomy remains successfully alternative. Iliac venous stenting complement is also crucial to treat associated Cockett syndrome. Endovascular thrombectomy devices may be a reasonable alternative to surgical thrombectomy.

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References

Vysetti S., Shinde S., Chaudhry S., et. al.: Phlegmasia cerulea dolens—a rare, life-threatening condition. Sci World J 2009;9:1105-6.

Chaochankit W, Akaraborworn O: Phlegmasia cerulea dolens with compartment syndrome. Ann Vasc Dis 2018;11:355-7.

Yang SS Yang SS, Yun WS: Surgical thrombectomy for phlegmasia cerulea dolens. Vasc Specialist Int 2016;32:201-4.

ACR Appropriateness Criteria Radiologic Management of Iliofemoral Venous Thrombosis, J Am Coll Radio 2020;17;5:S255-64.

Klok F.A., Huisman M.V.: Seeking optimal treatment for phlegmasia cerulea dolens. Thromb Res 2013;131:372-3.

Chinsakchai K., Ten Duis K., Moll F.L., et. al.: Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg 2011;45:5-14.

Veltchev LM, Kalniev MA, Todorov TA: Phlegmasia cerulean dolens - risk factors and prevention. J IMAB 2009,15:89-91.

Patel NH, Plorde JJ, Meissner M: Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens. Ann Vasc Surg 1998;12:471-5.

Schroeder M, Shorette A, Singh S, Budhram G: Phelgmasia cerulea dolens diagnosed by point- of-care ultrasound. Clin Pract Cases Emerg Med 2017;13:104-7.

Zhang Z, Chen Z, Sun Y, Xu M. Surgical Thrombectomy and Simultaneous Stenting for Phlegmasia Cerulea Dolens Caused by Iliac Vein Occlusion. Ann Vasc Surg 2018;51:239-45.

AbuRahma A.F., Perkins S.E., Wulu J.T., et. al. Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting. Ann Surg 2001;233:752-60.

Amin V.B., Lookstein R.A. Catheter-directed interventions for acute iliocaval deep vein thrombosis. Tech Vasc Interv Radiol 2014;17:96-102.

Meissner M.H. Rationale and indications for aggressive early thrombus removal. Phlebology 2012;27:78-84

Mewissen M.W., Seabrook G.R., Meissner M.H., et. al.: Catheter-directed thrombolysis of lower extremity deep vein thrombosis: report of a multicenter registry. Radiology 1999;211:39-49.

Rodríguez L.E., Aboukheir A., Figueroa-Vicente R., et. al.: Hybrid operative thrombectomy is noninferior to percutaneous techniques for the treatment of acute iliofemoral deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2016;5:177-84.

Kou C J, Batzlaff C, Bezzant M L, et al. (June 12, 2020) Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis. Cureus 12(6):e8587.

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Published

2022-07-01

How to Cite

1.
Pais F, Quintas A, Vieira I, Catarino J, Correia R, Bento R, Garcia R, Cardoso J, Ribeiro T, Ferreira R, Alves G, Bastos Gonçalves F, Ferreira ME. Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia. Angiol Cir Vasc [Internet]. 2022 Jul. 1 [cited 2024 Mar. 28];18(1):36-9. Available from: https://acvjournal.com/index.php/acv/article/view/358

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Section

Clinical Case