(1514) Thwarted Thrombus: A Case of Phlegmasia Cerulea Dolens Prevention

Introduction: Deep venous thrombosis (DVT) is rarely associated with compartment syndrome (CS), except in cases of phlegmasia cerulea dolens (PCD). We report a case of extensive lower extremity DVT that progressed to CS in the absence of the classical clinical features of PCD.

Description: A 55-year-old female with recently diagnosed stage IV bladder adenocarcinoma status post bilateral nephrostomy tubes and ongoing radiation therapy, developed left lower extremity (LLE) edema. A venous duplex ultrasound (US) demonstrated thrombi of the distal LLE deep veins. Due to ongoing hematuria, anticoagulation was deferred in favor of an inferior vena cava (IVC) filter. Ten days later, she developed respiratory distress requiring noninvasive mechanical ventilation, shock requiring vasopressors, and LLE pain. Vascular surgery was not concerned for compartment syndrome at this time. The patient was transferred to the medical intensive care unit; within an hour of admission, LLE exam progressed to firm compartments and pain with passive range of motion with no overlying skin changes. Repeat venous duplex US revealed extension of the LLE DVT to proximal deep veins. Laboratory assessment revealed lactic acidosis, but no rhabdomyolysis. Given concern for evolving CS the patient was taken for a four-compartment fasciotomy. Additionally, thrombectomy and IVC filter removal revealed large clot burden extending to the IVC and filter. She had an uneventful recovery with no major neurovascular sequelae.

Discussion: Frequent neurovascular monitoring in patients with extensive DVTs is crucial. High level of clinical suspicion and early identification of PCD or CS should prompt immediate intervention. DVT rarely progresses to shock without evidence of PCD which develops as a result of impaired resorption of interstitial fluid and increased pressures within the tissue. As the process progresses, the loss of intravascular plasma volume results in circulatory shock. Loss of arterial patency is multifactorial, including external compression and loss of hydrostatic pressure. Our case demonstrates successful early recognition and intervention preventing progression to PCD and enabling limb salvage. Ultimately, awareness of risk factors and early recognition is essential in reducing morbidity and mortality associated with PCD.