Venous gangrene: Difference between revisions
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*Extensive vascular congestion and venous ischemia | *Extensive vascular congestion and venous ischemia | ||
*Involves superficial collateral veins | *Involves superficial collateral veins | ||
* | *40-60% of phlegmasia cerulea dolens with capillary involvement progress to venous gangrene | ||
= | ===Risk Factors=== | ||
==Risk Factors== | |||
*Age 50-60s | *Age 50-60s | ||
*Malignancy (over half) | *Malignancy (over half) | ||
*Thrombophlebitis migrans | *Thrombophlebitis migrans | ||
*Acquired hemolytic anemia due to cold-antibodies | *Acquired [[hemolytic anemia]] due to cold-antibodies | ||
*Typical risk factors for DVT (pregnancy, surgery, trauma, hypercoagulable syndrome) | *Typical risk factors for [[DVT]] (pregnancy, surgery, trauma, hypercoagulable syndrome) | ||
*Idiopathic | *Idiopathic | ||
| Line 29: | Line 21: | ||
*Superficial gangrene and necrosis | *Superficial gangrene and necrosis | ||
*Arterial patency | *Arterial patency | ||
*Not reversible (vs. phlegmasia cerulea dolens and alba dolens are) | *Not reversible (vs. [[phlegmasia cerulea dolens]] and [[phlegmasia alba dolens]] are) | ||
*Fluid sequestration and circulatory shock | *Fluid sequestration and circulatory [[shock]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Venous thromboembolism types}} | |||
*Cellulitis | ===Others=== | ||
*Lymphedema | *[[Cellulitis]] | ||
*[[Lymphedema]] | |||
*Venous valvular insufficiency | *Venous valvular insufficiency | ||
*Superficial thrombophlebitis | *[[Superficial thrombophlebitis]] | ||
*Arterial embolism | *[[Arterial embolism]] | ||
*Diabetic ulcer | *[[Diabetic ulcer]] | ||
*Wet/gas gangrene | *Wet/gas [[gangrene]] | ||
== | |||
Clinical diagnosis | ==Evaluation== | ||
Duplex US | *Clinical diagnosis | ||
Contrast venography | *[[Ultrasound: DVT|Duplex US]] | ||
MRV | *Contrast venography | ||
*MRV | |||
==Management== | ==Management== | ||
*Interventional radiology consult for emergent catheter-directed thrombolysis | *Interventional radiology consult for emergent catheter-directed thrombolysis | ||
*Vascular surgery consult for thrombectomy | *Vascular surgery consult for thrombectomy | ||
*Steep limb elevation | *Steep limb elevation | ||
*Fluid resuscitation (PRBC) | *Fluid resuscitation ([[PRBC]]) | ||
*Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr | *[[Heparin]]: 80-100U/kg followed by infusion of 15-18U/kg/hr | ||
*Thrombolytic: Alteplase (1mg/min to total of 50mg) distal to thrombus | *Thrombolytic: [[Alteplase]] (1mg/min to total of 50mg) distal to thrombus | ||
==Disposition== | ==Disposition== | ||
*Admit | *Admit | ||
==See Also== | ==See Also== | ||
*[[Venous thromboembolism]] | |||
==External Links== | ==External Links== | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Cardiology]] | |||
[[Category:Orthopedics]] | |||
[[Category:Vascular]] | |||
Latest revision as of 18:54, 26 September 2019
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
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]
Others
- Cellulitis
- Lymphedema
- Venous valvular insufficiency
- Superficial thrombophlebitis
- Arterial embolism
- Diabetic ulcer
- Wet/gas gangrene
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
External Links
References
- ↑ 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.
- ↑ 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.