Day #251 - DVT (Phlegmasia Cerulea Dolens)

Today we heard a case of a patient who presented with an acute, cold/blue, painful leg. The cause of this was identified as a mixture of a large DVT on a background of peripheral vascular disease.

In phledmasia cerulea dolens (see right, from NEJM) the DVT, usually very large, causes venous outflow obstruction which, in turn, leads to elevated tissue pressures which can significantly reduce arterial flow leading to tissue ischemia.

In today's patient they presented with a lactic acidosis probably related to tissue hypoxemia.

There are a number of interesting articles about interventional and surgical approaches to the treatment of massive DVT causing PCD. The goal of therapy is to salvage the limb before it becomes gangrenous. This article discusses manual clot aspiration. This is a more complete review of the interventional options.

Note: in our case, thrombolysis was contraindicated because of the recent large ischemic stroke.

My colleague at TWH has posted a summary of the "Wells Criteria" for the clinical diagnosis of DVT.

Using this algorithm, a low risk patient with a negative D-dimer does not have a DVT. A high risk patient, or one with a positive D-dimer will require further investigation.

Duplex Compression Doppler Ultrasound is usually the test of choice. Treatment involves anticoagulation with heparin (unfractionated or low molecular weight depending on clinical scenario -- usually LMWH) which is generally followed by coumadin after 2 days of anticoagulation with overlap until INR 2-3 x 2 days and a minimum of 5 days of heparin