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Lipodermatosclerosis (LDS), also known as sclerosing panniculitis, is a chronic inflammatory condition of the skin and subcutaneous tissue caused by longstanding venous insufficiency. Often misdiagnosed as cellulitis due to overlapping clinical features, it requires accurate diagnosis and a multifaceted management approach. This clinical review explores the epidemiology, pathophysiology, clinical presentation, diagnostic challenges and management strategies for LDS. Acute LDS manifests with erythema and induration similar to cellulitis, while chronic LDS is characterised by fibrosis and skin tightening. Key management strategies include compression therapy, lifestyle modifications and interventions targeting venous insufficiency. Challenges such as delayed diagnosis, poor adherence to therapy and limited evidence for systemic treatments may compromise the quality of patient care. Future directions emphasise novel therapeutic approaches, evaluation of current treatments and the integration of artificial intelligence to enhance diagnostic decisions. Increased clinician awareness and research into the epidemiology, pathogenesis and treatment of LDS remain essential to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Dilated, convoluted, subcutaneous veins measuring more than 3 mm in diameter when measured while upright and exhibiting reflux are called varicose veins. Varicose veins present a significant financial burden on the healthcare system, causing morbidity and lost work hours. Endovenous Laser Ablation (EVLA), a minimally invasive endovenous intervention that uses heat energy to induce aseptic inflammation of the vessel wall, obstructs and eliminates reflux. This technique has gained more attention recently because it eliminates the need for open surgical incisions. In contrast, standard surgery entails making an incision in the groin and excising the great saphenous vein anatomically to eliminate the abnormal reflux. Numerous studies have demonstrated the effectiveness of both thermal and non thermal endovenous methods in treating reflux in patients with axial venous reflux. However, there are limited comparative studies between various endovenous therapy modalities and traditional surgery concerning postoperative clinical outcomes. Aim: To evaluate the treatment outcomes of patients with Clinical (C), Aetiological (E), Anatomical (A), and Pathophysiological (P) - CEAP class C2-C6 who underwent either Endovenous Laser Ablation (EVLA) or conventional surgery for varicose veins. Materials and Methods: A prospective interventional study was conducted in the Department of General Surgery at Shri BM Patil Medical College Hospital and Research Centre, BLDE (Deemed to be University), Vijayapura, Karnataka, India, that included all patients with CEAP classes C2-C6, from July 2022 to July 2024. A block randomisation method was used to allocate patients into two groups to ensure an equal distribution of demographic variables. Group A (n=39) underwent EVLA and Group B (n=35) underwent flush ligation of the saphenofemoral junction and stripping. Data were collected with a particular focus on the duration of surgery, duration of hospital stay, postoperative pain, and cosmetic acceptance, with a follow-up period of six months. Additionally, potential procedural complications and recurrence rates were assessed after the six-month follow-up. Statistical analyses were performed using Statistical Packages for Social Sciences (SPSS) version 25.0. The Wilcoxon rank sum test and Chi-square test/Fisher's-exact test were used, with a p-value of <0.05 considered significant. Results: The mean age of patients was noted to be 42.02±9.73 years in cases and 44.51±8.23 years in controls. In the present study, Group A (n=39) underwent EVLA, of which 36 were males and 3 were females. Group B (n=35) underwent conventional surgery, comprising 31 males and 4 females. The mean operating time in Group A (cases) was 38 minutes, whereas in Group B (controls), it was 60 minutes. Operative time was shortened by 37%, thereby avoiding prolonged exposure to anaesthetic medication. The mean pain score in Group A (cases) was 1.94, compared to 4.48 in Group B (controls). Postoperative pain was significantly reduced by 53% in the EVLA group compared to the conventional surgery group. The mean duration of postoperative hospital stay was 2.51 days for cases and 5.88 days for controls. The hospital stay was shortened by 57%, highlighting the efficacy of EVLA in enhancing patient recovery. In Group A (cases), post- EVLA burns were observed in 1 (2.5%) patient, which healed spontaneously over two weeks. Skin discolouration was observed in 3 (7.6%) patients, which reduced spontaneously over 3-4 weeks. In Group B (controls), seroma was observed in 1 (2.8%) patient, for which suture removal and drainage were performed, followed by secondary suturing on day 4, leading to a prolonged hospital stay. Bruising was observed in 1 (2.8%) patient, which resolved over 3-4 weeks. Wound infection at the groin incision site was observed in 5 (14.2%) patients, for which daily dressings were conducted, and intravenous antibiotics were continued for five days. The case group experienced significantly lower complications postoperatively when compared with the control group, with a p-value of 0.008. Patients were interviewed at the end of the follow-up period regarding their subjective cosmetic outcomes. Total 14 (40%) patients in the conventional surgery group were unsatisfied with their scars, whereas only 1 (2.5%) patient in the EVLA group expressed dissatisfaction with the cosmetic outcome. However, no recurrences were observed in either group during the six-month follow-up. Conclusion: The EVLA is a better treatment modality for primary lower limb varicosities in terms of procedure duration, postoperative pain, hospital stay duration, and overall cosmetic acceptance by the patients. [ABSTRACT FROM AUTHOR]

The presented case contains a successful surgical correction of venous stasis of an autograft that occurred in the early postoperative period during the delayed reconstruction of the left breast with a free TRAM flap in a patient after radical surgical treatment of stage 3A pT2N2M0 breast cancer. Using the microsurgical technique, two venous anastomoses were sequentially applied, which made it possible to keep the transplanted flap completely viable and, thus, to ensure a successful outcome of the reconstructive surgery.

An otherwise healthy 27-year-old woman presented with bilateral blurry vision and was found to have diffuse posterior venous stasis with significant retinal ischemia. On further examination, she was found to have chronic myeloid leukemia with life-threatening leukocytosis. Prompt systemic treatment can result in near-complete resolution of any ocular pathology Purpose: The following case report highlights a rare presentation of chronic myeloid leukemia-associated hyper-viscosity syndrome and provides a brief review of expected findings and treatment outcomes. Methods: An otherwise healthy 27-year-old woman presented to the ophthalmology clinic with mild bilateral blurriness (20/20 in both eyes) and prolonged light adaption in the morning for several months. Examination demonstrated severe bilateral venous stasis, white-centered hemorrhages, intraretinal hemorrhage, and peripheral ischemia with diffuse leakage. Results: Same-day CBC demonstrated a leukocytosis of >600,000. Subsequent bone marrow biopsy confirmed the 9,22 translocation (Philadelphia chromosome). On further examination, the patient had an enlarged cardiac silhouette, cytopenia, and splenomegaly past the umbilicus, consistent with a severe and life-threatening leukostasis. Conclusion: Ocular involvement can occur in acute and chronic leukemia. Five to ten percentage of patients present to an eye physician first, without a known diagnosis. Prompt systemic treatment can result in near-complete reversal of any intraocular injury in most mild-to-moderate cases, as was the case here. [ABSTRACT FROM AUTHOR]

Osteoarthritis (OA) is now considered as a multifaceted disease affecting various articular tissues, including cartilage, bone, synovium, and surrounding ligaments. The pathophysiology strongly implicates intricate chemical communication, primarily through cytokines, leading to the production of degradative enzymes in cartilage, inflammatory peptides in synovium, and structural changes in bone, resulting in characteristic clinical features such as joint deformities and loss of cartilage space seen on X-rays. Recent studies highlight the previously underestimated role of subchondral bone in OA, revealing its permeability to cytokines and raising questions about the influence of abnormal perfusion on OA pathophysiology, suggesting a vascular component in the disease’s etiology. In essence, alterations in bone perfusion, including reduced venous outflow and intraosseous hypertension, play a crucial role in influencing the physicochemical environment of subchondral bone, impacting osteoblast cytokine expression and contributing to trabecular remodeling, changes in chondrocyte phenotype, and ultimately cartilage matrix degeneration in OA. Dynamic contrast (gadolinium) enhanced magnetic resonance imaging (DCE-MRI) was used to quantify perfusion kinetics in normal and osteoarthritic subchondral bone, demonstrating that decreased perfusion temporally precedes and spatially correlates with cartilage lesions in both young Dunkin-Hartley (D-H) guinea pigs and humans with osteoarthritis. Pharmacokinetic analysis of DCE-MRI generated data reveals decreased tracer clearance and outflow obstruction in the medial tibial plateau of osteoarthritic guinea pigs, coinciding with progressive cartilage degradation, loss of Safranin O staining, and increased expression of matrix metalloproteinases and interleukin-1. Positron emission tomographic (PET) scanning using 18F-Fluoride reveals a relationship among bone blood flow, cartilage lesions, and 18F-Fluoride influx rate in OA, highlighting the intricate relationships between decreased perfusion, altered bone metabolism, and the progression of osteoarthritis. These findings, supported by 18F-Fluoride PET data, suggest the presence of venous stasis associated with outflow obstruction, emphasizing the role of decreased subchondral bone perfusion in the pathophysiology of OA and its association with reduced osteoblast activity and advanced cartilage degeneration.

Bone marrow edema (BME), also termed bone marrow lesions, is a syndrome characterized by bone pain and the appearance of high signal intensity on T2 fat-suppressed and short tau inversion recovery (STIR) MRI sequences. BME can be related to trauma or a variety of non-traumatic diseases, and current treatment modalities include non-steroidal anti-inflammatory drugs (NSAIDS), bisphosphonates, denosumab, extracorporeal shockwave therapy (ESWT), the vasoactive prostacyclin analogue iloprost, and surgical decompression. Spontaneous BME is a subset that has been observed with no apparent causative conditions. It is most likely caused by venous outflow obstruction and intraosseous hypertension. These are mechanistically related to impaired perfusion and ischemia in several models of BME and are related to bone remodeling. The association of perfusion abnormalities and bone pain provides the pathophysiological rationale for surgical decompression. We present a case of spontaneous BME and a second case of spontaneous migratory BME treated with surgical decompression and demonstrate resolution of pain and the high signal intensity on MRI. This report provides an integration of the clinical syndrome, MR imaging characteristics, circulatory pathophysiology, and treatment. It draws upon several studies to suggest that both the bone pain and the MRI characteristics are related to venous stasis, and when circulatory pathologies are relieved by decompression or fenestration, both the bone pain and the MRI signal abnormalities resolve. [ABSTRACT FROM AUTHOR]

Knee scooters are commonly used for mobility instead of other devices. However, passive popliteal venous flow impedance has been observed with knee scooter usage ostensibly as a result of deep knee flexion. This study aimed to characterize the magnitude of impact knee flexion has on popliteal venous flow in relation to the degree of knee flexion when walking boot immobilized. Furthermore, the countervailing effect of standardized pedal musculovenous pump (PMP) activation was observed. Popliteal venous diameter and flow metrics were assessed with venous ultrasonography in 24 healthy individuals. Straight leg, crutch, and knee scooter positioning while wearing a walking boot and non–weight-bearing were compared. Flow was assessed with muscles at rest and with PMP activation. Of 24 participants, 16 (67%) were female. Twelve limbs (50%) were right sided. The mean age was 21.9 (SD = 3.0) years, and the mean body mass index was 21.9 (SD 1.9) kg/m2. Observer consistencies were excellent (intraclass correlation range = 0.93 to 0.99). No significant differences in mean vessel diameter, time-averaged mean velocity, and total volume flow occurred (all P >.01). Corresponding knee flexion effect sizes were small (range = −0.04 to −0.26). A significant decrease (−24%) in active median time-averaged peak velocity occurred between upright and crutch positions (20.89 vs 15.92 cm/s; P <.001) with a medium effect size (−0.51). PMP activation increased all flow parameters (all P <.001), and effect sizes were comparatively larger (>0.6) across all knee flexion positions. Clinical Significance: Knee flexion has a small to medium impact on popliteal venous return in healthy patients. Active toe motion effectively counters the negative effects of gravity and knee flexion when the ankle is immobilized. Levels of Evidence: Therapeutic, Level IV [ABSTRACT FROM AUTHOR]

A 50-year-old man was referred to our hospital for colitis with abdominal pain and diarrhea that had persisted for more than 8 months. 9 months earlier, he had been treated for fulminant eosinophilic myocarditis. During steroid therapy, ulceration appeared in the esophagus, stomach and large intestine. The biopsy results showed cytomegalovirus (CMV) inclusion bodies, and the patient was diagnosed with CMV gastrocolitis and treated with ganciclovir. Colonoscopy 7 months earlier revealed ischemia-like segmental colitis 10 cm in length in the hepatic flexure without evidence of CMV infection. Colonoscopy after 1 month and 3 months showed no improvement. We suspected drug-induced focal ischemic colitis, and discontinued eplerenone. Colonoscopy 2 months after withdrawal of eplerenone showed improvement in colitis, and colonoscopy 8 months later showed ulcer healing. Venous disorders are cautioned as a known side effect of eplerenone, but this is the first report of venous stasis colitis thought to be caused by eplerenone. [ABSTRACT FROM AUTHOR]

Dermatophlebology refers to the study of dermal alterations that occur with transmitted high venous pressure. These changes may range from telangiectasia, complex dermal vascular conditions, and all changes in Clinical Etiology Anatomical Pathophysiology classes IV-VI. Understanding the underlying pathophysiology is essential to treating the skin manifestations of venous disease. [ABSTRACT FROM AUTHOR]

The research and treatment of venous problems are the focus of the specialized field of medicine known as phlebology, which has advanced significantly in recent years. Phlebologists have worked to innovate the diagnosis, management, and treatment of problems like varicose veins, deep vein thrombosis, and chronic venous The research and treatment of venous problems are the focus of the specialized field of medicine known as phlebology, which has advanced significantly in recent years. Phlebologists have worked to innovate the diagnosis, management, and treatment of problems like varicose veins, deep vein thrombosis, and chronic venous. [ABSTRACT FROM AUTHOR]

Background: To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods: A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results: 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion: Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate. [ABSTRACT FROM AUTHOR]

Background: This randomised controlled trial investigates the dosing effect of neuromuscular electrical stimulation (NMES) in patients with chronic venous disease (CVD). Methods: Seventy-six patients with CEAP C3-C5 were randomised to Group A (no NMES), B (30 minutes of NMES daily) or C (60 minutes of NMES daily). Primary outcome was percentage change in Femoral Vein Time Averaged Mean Velocity (TAMV) at 6 weeks. Clinical severity scores, disease-specific and generic quality of life (QoL) were assessed. Results: Seventy-six patients were recruited - mean age 60.8 (SD14.4) and 47:29 male. Six patients lost to follow-up. Percentage change in TAMV (p<0.001) was significantly increased in Groups B and C. Aberdeen Varicose Veins Questionnaire Score (-6.9, p=0.029) and Venous Clinical Severity Score (-4, p-0.003) improved in Group C, and worsened in Group A (+1, p=0.025). Conclusions: Daily NMES usage increases flow parameters, with twice daily usage improving QoL and clinical severity at 6 weeks in CVD patients. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID-19) predisposes to deep vein thrombosis (DVT) and pulmonary embolism (PE) particularly in mechanically ventilated adults with severe pneumonia. The extremely high prevalence of DVT in the COVID-19 patients hospitalized in the intensive care unit (ICU) has been established between 25 and 84% based on studies including systematic duplex ultrasound of the lower limbs when prophylactic anticoagulation was systematically administrated. DVT prevalence has been shown to be markedly higher than in mechanically ventilated influenza patients (6–8%). Unusually high inflammatory and prothrombotic phenotype represents a striking feature of COVID-19 patients, as reflected by markedly elevated reactive protein C, fibrinogen, interleukin 6, von Willebrand factor, and factor VIII. Moreover, in critically ill patients, venous stasis has been associated with the prothrombotic phenotype attributed to COVID-19, which increases the risk of thrombosis. Venous stasis results among others from immobilization under muscular paralysis, mechanical ventilation with high positive end-expiratory pressure, and pulmonary microvascular network injuries or occlusions. Venous return to the heart is subsequently decreased with increase in central and peripheral venous pressures, marked proximal and distal veins dilation, and drops in venous blood flow velocities, leading to a spontaneous contrast “sludge pattern” in veins considered as prothrombotic. Together with endothelial lesions and hypercoagulability status, venous stasis completes the Virchow triad and considerably increases the prevalence of DVT and PE in critically ill COVID-19 patients, therefore raising questions regarding the optimal doses for thromboprophylaxis during ICU stay.

Coronavirus disease 2019 (COVID-19) predisposes to deep vein thrombosis (DVT) and pulmonary embolism (PE) particularly in mechanically ventilated adults with severe pneumonia. The extremely high prevalence of DVT in the COVID-19 patients hospitalized in the intensive care unit (ICU) has been established between 25 and 84% based on studies including systematic duplex ultrasound of the lower limbs when prophylactic anticoagulation was systematically administrated. DVT prevalence has been shown to be markedly higher than in mechanically ventilated influenza patients (6–8%). Unusually high inflammatory and prothrombotic phenotype represents a striking feature of COVID-19 patients, as reflected by markedly elevated reactive protein C, fibrinogen, interleukin 6, von Willebrand factor, and factor VIII. Moreover, in critically ill patients, venous stasis has been associated with the prothrombotic phenotype attributed to COVID-19, which increases the risk of thrombosis. Venous stasis results among others from immobilization under muscular paralysis, mechanical ventilation with high positive end-expiratory pressure, and pulmonary microvascular network injuries or occlusions. Venous return to the heart is subsequently decreased with increase in central and peripheral venous pressures, marked proximal and distal veins dilation, and drops in venous blood flow velocities, leading to a spontaneous contrast "sludge pattern" in veins considered as prothrombotic. Together with endothelial lesions and hypercoagulability status, venous stasis completes the Virchow triad and considerably increases the prevalence of DVT and PE in critically ill COVID-19 patients, therefore raising questions regarding the optimal doses for thromboprophylaxis during ICU stay. [ABSTRACT FROM AUTHOR]

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Venous stasis ulcers represent the majority of lower-extremity ulcers and place a considerable financial burden on the American health care system. Current standard of care therapies remain sub-optimal with 50% of venous stasis ulcers remaining unhealed after 4 months. Sixteen consecutive wounds were enrolled across 8 participants at a single center and underwent pH-driven therapy in addition to standard care as dictated by physicians. Following wound debridement, the pH of the wound bed was measured using pH strips. If acidic, normal saline was used to rinse the wound at every dressing change. If alkaline, nonsterile gauze was soaked in 0.25% acetic acid and applied to the wound for a minimum of 30 seconds. Participants were followed for 4 weeks with research staff observing compliance throughout. All 16 wounds had an alkaline pH at baseline, with an average pH of 8.25 ± 0.55 (range 7.5 to 9). Average area of the wound at the time of enrollment was (mean ± standard deviation) 285.48 ± 43.68 mm2, and average age of the wound was 37.5 ± 20.3 months (range 3 to 72). A simple linear regression model found a moderate relationship between pH and the rate of healing of chronic nonhealing venous stasis lower-extremity wounds (correlation coefficient = 0.61). For every 1-unit change in pH, we can expect to see a change in wound size of 116.05 mm2. This is the first US-based, open-label, prospective study that examined the effect of pH on the rate of healing in chronic nonhealing venous stasis ulcer lowerextremity wounds. [ABSTRACT FROM AUTHOR]

Background. Non-healing wounds are becoming a growing concern for public health as a result of their increasing prevalence in progressively aging societies. Objectives. The aim of this article is to evaluate the effects of wound etiology on a panel of circulating cytokines in patients with non-healing wounds of the lower extremities. Material and methods. This prospective case-control study involved 104 individuals: healthy elderly people (n = 46) and patients with diabetes and/or cardiovascular disease (n = 58; among them 38 with chronic wounds of venous, ischemic or neurotrophic etiology). Selected serum cytokines - i.e. IL-1ß, IL-4, IL-6, IL-8, FGF-2, G-CSF, GM-CSF, MCP-1, MIP-1a, TNF-a, VEGF-A, and PDGF-BB - were measured using the Luminex platform. Results. Compared to healthy elderly people, presence of diabetes and/or cardiovascular disease was associated with elevated IL-6, IL-8, MCP-1 and G-CSF while non-healing wounds coexisted with the increase in the levels of all examined cytokines/growth factors except for G-CSF and GM-CSF. Among diseased elderly people, having wounds was associated with increased levels of IL-1ß, IL-4, IL-6, IL-8, FGF-2, MIP-1a, PDGF-BB, and VEGF-A. Interleukin 1ß elevation was a sole independent predictor of chronic wounds with an odds ratio (OR) of 6.3. Cytokines in healthy seniors were loosely interrelated, while the levels of cytokines in diseased patients with wounds displayed a tight pattern of association. When stratified by their etiology, the association pattern for IL-6, IL-8, MCP-1, and VEGF-A was disrupted in neurotrophic wounds. Conclusions. The results presented herein may improve our understanding of the pathomechanisms which lead to chronic wounds and of the effects they exert on a systemic level, as well as providing potential targets for more effective therapies. [ABSTRACT FROM AUTHOR]

Gout is the oldest and the most prevalent inflammatory joint disease worldwide exhibiting a steady increase in both incidence and prevalence. Despite millennia of rigorous clinical research, specific pivotal questions still need to be fully elucidated. Presently, the exact initial defect that induces its most prevalent type—primary hyperuricemia and primary gout—remains idiopathic. Additionally, the remarkable predilection for foot involvement (podagra), its exceptionally intense pain, and the precise mechanism triggering acute gout attack all lack clear pathological processes. This manuscript aims to demystify the aforementioned dilemmas by presenting the barotoxicity hypothesis which introduces the barotoxic effect of intra-abdominal pressure on the renal and pedal venous circulations as the potential origin of primary hyperuricemia and the subsequent podagra formation in addition to presenting evidence in support of this hypothesis. If validated, the barotoxicity hypothesis could radically transform our modern understanding of this ancient ailment, reframing gout from being a metabolic arthropathy to a mechanical phlebopathy. Moreover, future therapeutic interventions could pivot towards alleviating intra-abdominal pressure and subsequent peripheral venous stasis, offering innovative preventative and therapeutic approaches. [ABSTRACT FROM AUTHOR]

Objectives To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. Methods This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. Results Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 (P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. Conclusion These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome. [ABSTRACT FROM AUTHOR]

Objective Venous stasis is a risk factor for venous thromboembolism. We aimed to determine the efficacy of forceful foot exercises for actuation of the calf muscle pump to counteract stasis. Methods We examined 20 seated healthy subjects. The peak systolic velocity at the level of the popliteal vein was assessed by Doppler ultrasound. Results The mean peak systolic velocity measurements (in cm/s) were as follows: baseline = 5.6; ankle plantar flexion with toe flexion = 91.0; toe touch heel lift = 107.4; ankle dorsiflexion with toe extension = 193.6; isolated flexion of all toes = 118.8; ankle plantarflexion with 100 and 250 Newton forefoot force = 89.9 and 154.5, respectively. Conclusion All exercises achieved significant increases in peak systolic velocity compared to baseline. Ranking showed that forceful ankle dorsiflexion, plantarflexion with 250 Newtons and forceful flexion of all toes yielded the highest mean peak systolic velocity values (193.6, 154.5, and 118.8 cm/s, respectively). [ABSTRACT FROM AUTHOR]

Background: Deep vein thrombosis (DVT) is a common disease that is diagnosed in approximately 1 in 1000 adults annually. Extensive DVT can lead to life- or limb-threatening diagnoses such as phlegmasia cerulea dolens (PCD), phlegmasia alba dolens, and venous gangrene. PCD, also known as massive iliofemoral venous thrombosis, is rare, and a severe complication of DVT.Case Report: We report a case of a 94-year-old bedridden woman with past medical history of dementia, hypertension, pulmonary embolism, DVT, and atrial fibrillation. The patient was admitted to the hospital for bright red blood per rectum and an elevated international normalized ratio (INR) of 5.7. On admission, her dose of warfarin was suspended and she was given 4 units of fresh frozen plasma as well as 10 mg of i.v. vitamin K. She was discharged home with an INR normalized to 1.3 and cessation of her rectal bleeding. At discharge, she was not restarted on warfarin, nor was any bridging therapy used. The patient returned to the Emergency Department a week later for worsening pain and bluish discoloration of her bilateral lower extremities. An ultrasound (US) examination showed that she had developed bilateral PCD, after INR reversal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians commonly care for patients who present with acute DVT or treat patients on anticoagulant therapy who require cessation of medications or administration of prothrombotic agents to reverse bleeding. Cases of extensive clot burden leading to PCD have been reported in the literature, however, reports of bilateral PCD secondary to cessation of warfarin have been scarce. PCD should be considered carefully as one of the complications in warfarin reversal, as it requires immediate attention and surgical intervention to prevent limb loss. [ABSTRACT FROM AUTHOR]