66-year-old woman with a history of small-cell lung cancer presents for leg pain and swelling

Initiate therapy with low molecular weight heparin and consult vascular surgery/interventional radiology for possible thrombolysis or thrombectomy.

Educational Objective:

Recognize and manage the manifestations of phlegmasia cerulea dolens.

Key Point:

Phlegmasia cerulea dolens is due to a deep venous occlusion and can lead to limb ischemia.

Explanation:

This patient developed phlegmasia cerulea dolens due to massive iliofemoral DVT that occluded the venous drainage of her leg that, in turn, can cause compartment syndrome, gangrene, and limb ischemia. The next step in the management of this patient's condition would be to initiate therapy with low molecular weight heparin. and to obtain an interventional radiology consultation for the possible need for thrombolytic therapy or thrombectomy. Some patients will respond promptly to heparin along with supportive measures such as elevation of the affected leg and fluid resuscitation.

Neither warfarin nor dabigatran (an oral direct thrombin inhibitor), would be appropriate in this setting given their longer-lasting effects and the possible need for emergent intervention. Low molecular weight heparin is preferred over unfractionated heparin.

References:

Lip G, Hull R. Overview of the treatment of lower extremity deep venous thrombosis (DVT). Revised June 15, 2017. Accessed October 3, 2017.

Meissner MH, Gloviczki P, Comerota AJ, et al. Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2012;55:1449.