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

Clinical Spectrum of Venous Thromboembolism

• Deep venous thrombosis (uncomplicated)
• Phlegmasia alba dolens
• Phlegmasia cerulea dolens
• Venous gangrene
• Pulmonary embolism

Only 40% of ambulatory ED pts w/ PE have concomitant DVT

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 alba dolens are)
• Fluid sequestration and circulatory shock

Differential Diagnosis

• Phlegmasia cerulea dolens
• DVT
• Cellulitis
• Lymphedema
• Venous valvular insufficiency
• Superficial thrombophlebitis
• Arterial embolism
• Diabetic ulcer
• Wet/gas gangrene

Workup

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

Sources

• Dardik A. (2014, Feb 25). Phlegmasia Alba and Cerulea Dolens. eMedicine. Retrieved 12/21/2014 from http://emedicine.medscape.com/article/461809-overview.
• Sutton RA. Venous gangrene. Br Med J. 1966; 1(5501):1465-1466.
• Ross, JV, et al. Gangrene of lower extremity secondary to extensive venous occlusion. Circulation. 1961; 24: 549-556.