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 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

External Links

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.