Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia
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...
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Sociedade Portuguesa de Angiologia e Cirurgia Vascular
2022-07-01
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| Series: | Angiologia e Cirurgia Vascular |
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| Online Access: | https://acvjournal.com/index.php/acv/article/view/358 |
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| author | Fábio Pais Anita Quintas Isabel Vieira Joana Catarino Ricardo Correia Rita Bento Rita Garcia Joana Cardoso Tiago Ribeiro Rita Ferreira Gonçalo Alves Frederico Bastos Gonçalves Maria Emília Ferreira |
| author_facet | Fábio Pais Anita Quintas Isabel Vieira Joana Catarino Ricardo Correia Rita Bento Rita Garcia Joana Cardoso Tiago Ribeiro Rita Ferreira Gonçalo Alves Frederico Bastos Gonçalves Maria Emília Ferreira |
| author_sort | Fábio Pais |
| collection | DOAJ |
| description |
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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| first_indexed | 2024-04-10T22:39:37Z |
| format | Article |
| id | doaj.art-79c2b9664d634528ab7aadd68bfae71f |
| institution | Directory Open Access Journal |
| issn | 1646-706X 2183-0096 |
| language | Portuguese |
| last_indexed | 2024-04-10T22:39:37Z |
| publishDate | 2022-07-01 |
| publisher | Sociedade Portuguesa de Angiologia e Cirurgia Vascular |
| record_format | Article |
| series | Angiologia e Cirurgia Vascular |
| spelling | doaj.art-79c2b9664d634528ab7aadd68bfae71f2023-01-16T08:56:38ZporSociedade Portuguesa de Angiologia e Cirurgia VascularAngiologia e Cirurgia Vascular1646-706X2183-00962022-07-0118110.48750/acv.358Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasiaFábio Pais0Anita Quintas1Isabel Vieira2Joana Catarino3Ricardo Correia4Rita Bento5Rita Garcia6Joana Cardoso7Tiago Ribeiro8Rita Ferreira9Gonçalo Alves10Frederico Bastos Gonçalves11Maria Emília Ferreira12Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, PortugalAngiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal Angiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, PortugalAngiology and Vascular Surgery Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal 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. https://acvjournal.com/index.php/acv/article/view/358Venus thrombosisdeep venous thrombosisphlegmasia ceruleaendovascular catheter-directed thrombolysisCockett Syndromethrombectomy |
| spellingShingle | Fábio Pais Anita Quintas Isabel Vieira Joana Catarino Ricardo Correia Rita Bento Rita Garcia Joana Cardoso Tiago Ribeiro Rita Ferreira Gonçalo Alves Frederico Bastos Gonçalves Maria Emília Ferreira Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia Angiologia e Cirurgia Vascular Venus thrombosis deep venous thrombosis phlegmasia cerulea endovascular catheter-directed thrombolysis Cockett Syndrome thrombectomy |
| title | Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia |
| title_full | Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia |
| title_fullStr | Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia |
| title_full_unstemmed | Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia |
| title_short | Venous thrombectomy after failure of catheter-directed thrombolysis for the treatment of three cases of phlegmasia |
| title_sort | venous thrombectomy after failure of catheter directed thrombolysis for the treatment of three cases of phlegmasia |
| topic | Venus thrombosis deep venous thrombosis phlegmasia cerulea endovascular catheter-directed thrombolysis Cockett Syndrome thrombectomy |
| url | https://acvjournal.com/index.php/acv/article/view/358 |
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