Venous gangrene

Background
  • Massive iliofemoral or IVC occlusion with patent arteries
  • Extensive vascular congestion and venous ischemia
  • Involves superficial collateral veins
  • 40-60% of phlegmasia cerulea dolens with capillary involvement progress to venous gangrene

Risk Factors
  • Age 50-60s
  • Malignancy (over half)
  • Thrombophlebitis migrans
  • Acquired hemolytic anemia due to cold-antibodies
  • Typical risk factors for DVT (pregnancy, surgery, trauma, hypercoagulable syndrome)
  • Idiopathic

Clinical Features
  • Limb pain
  • Severe edema
  • Cyanosis
  • Blistering and extravasation
  • Purplish black well-circumscribed areas
  • Superficial gangrene and necrosis
  • Arterial patency
  • Not reversible (vs. phlegmasia cerulea dolens and phlegmasia alba dolens are)
  • Fluid sequestration and circulatory shock

Differential Diagnosis

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]

Others

Evaluation
  • Clinical diagnosis
  • Duplex US
  • Contrast venography
  • MRV

Management
  • Interventional radiology consult for emergent catheter-directed thrombolysis
  • Vascular surgery consult for thrombectomy
  • Steep limb elevation
  • Fluid resuscitation (PRBC)
  • Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
  • Thrombolytic: Alteplase (1mg/min to total of 50mg) distal to thrombus

Disposition
  • Admit

See Also

References
  1. Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
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