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Venous gangrene represents the most severe manifestation following deep venous thrombosis (DVT), and presents as acral ischaemic necrosis. The pathophysiology is driven by an acquired coagulopathic state leading to microvascular thrombosis outcomes are generally poor. This study was aimed at analysing the outcomes in these rare group of patients who presented with venous gangrene at a single institution during a two year period.

Resumen La flegmasia cerulea dolens es una complicación rara y poco frecuente de la trombosis venos a profunda. Los principales factores predisponentes son los procesos neoformativos, estados de hiper coagulabilidad, insuficiencia cardíaca congestiva, embarazo, inmovilización prolongada y cirugías. Se caracteriza por edema masivo, dolor intenso y cianosis. Sin tratamiento evoluciona con isquemia, necrosis y amputación del miembro comprometido. No existe consenso en su tratamiento, pero éste debe ser rápido, multidisciplinario y agresivo. La anticoagulación con heparina, la fibrinólisis sistémica, la trombectomía percutánea con fibrinólisis local, la trombectomía quirúrgica, la fasciotomía, la colocación de filtro de vena cava inferior y la amputación son algunos de los tratamientos propuestos. Abstract Phlegmasia cerulea dolens (FCD) is a rare complication of deep vein thrombosis. Its cause is unknown. The main predisposing factors for the disease are neoformative processes, hypercoagulable states, congestive heart failure, pregnancy, prolonged immobilization, and surgeries on the affected limb. FCD is characterized by massive edema, severe pain, and cyanosis. The diagnosis is clinical. It is associated in most cases with pulmonary embolism and can lead to loss of the compromised limb if not treated in time. So far there is no consensus on its treatment. In clinical practice the use of anticoagulation with heparin, local thrombolysis, systemic fibrinolysis, surgical thrombectomy, fasciotomy, and inferior vena cava filter are described. In irreversible cases amputation is required. We present the case of a patient with FCD, the treatment performed and the evolution.

Venous gangrene is rare and hard to diagnose. Here, we present a 65-year-old man with rectal cancer receiving chemotherapy. He suffered from ventricular tachycardia and regained spontaneous circulation after cardiopulmonary resuscitation. Thereafter, both hands became swollen and blue. The ischemia due to shock was impressed. However cyanosis and swelling of hands progressed, although the patient's vital sign remained stable. Fasciotomy was arranged for both hands. After 12 days. The right hand became gangrenous change and amputation with muscle flap plus fasciocutaneous flap was performed. The venous gangrene was confirmed by pathological report of the amputated hand.

Phlegmasia cerulea dolens (PCD) is a medical emergency that can lead to venous gangrene of the lower extremity. Early diagnosis and prompt treatment is crucial for limb salvage. There are two treatment options (endovascular or surgical). In the endovascular era, catheter-directed thrombolysis is the treatment of choice to achieve venous outflow. However, surgical thrombectomy is indicated in certain cases. The authors report successful surgical thrombectomy in a 75-year-old man with PCD and review the treatment of PCD.

Ein Verschluss der kompletten venosen Ausstrombahn wird als Phlegmasia coerulea dolens (PCD) bezeichnet. Hierbei kommt es durch den massiven Ruckstau des Bluts zu einem sprunghaften Anstieg des Gewebedrucks. Durch die Entwicklung eines Kompartmentsyndroms kommt es konsekutiv zu einer arteriellen Minderperfusion bis hin zu einer venosen Gangran. Aufgrund der geringen Ischamietoleranz des Gewebes gelten in der Diagnostik und der Behandlung einer PCD andere Voraussetzungen als bei der inkompletten tiefen Beinvenenthrombose. Welche therapeutischen Optionen bestehen bei einem kompletten Verschluss der venosen Ausstrombahn? Eine konservative Therapie kommt aufgrund der hohen Mortalitatsrate nicht infrage. Ohne zeitliche Verzogerung muss vielmehr eine wegweisende Diagnostik und rekanalisierende Therapie angestrebt werden. Den Goldstandard in der Therapie der PCD stellt aktuell die operative Therapie dar. Die interventionelle Behandlung der PCD ist eine Behandlungsalternative im Anfangsstadium der Erkrankung oder bei fehlender operativer Therapiemoglichkeit. Eine Fasziotomie ist bei einer erfolgreichen Rekanalisation dann meist nicht mehr erforderlich. Die Datenlage hinsichtlich der seltenen Erkrankung ist weiterhin gering und beschrankt sich zumeist auf Falldarstellungen.

Successful treatment of the lower limbs purulent necrotic injury regardless etiopathogenesis feasible by a multidisciplinary approach in a specialized or general hospital. This case demonstrates the successful implementation of a multidisciplinary approach in a general hospital using modern methods to the treatment of the lower limbs purulent necrotic injures in cases of the background phlegmasia cerulea dolens as the paraneoplastic syndrome.

Highlights • Extensive thrombosis, absent/contraindicated thrombolysis, inefficient conservative treatment – encourage venous clot removal. • Venous thrombectomy, with fasciotomy and delayed necrectomy, may be considered for limb salvage in selected acute cases. • Due to high chances of severe post-thrombotic morbidity, ileofemoral phlegmasia patients may benefit the most from timely venous thrombectomy., Introduction Warfarin anticoagulation of oncologic patients with DVT may paradoxically progress to phlegmasia cerulea dolens and limb gangrene, due to cancer-associated disseminated intravascular coagulation. This case report, written in line with the SCARE criteria, endorses venous thrombectomy in selected patients to attempt limb salvage. A young woman’s warfarin associated acute ileofemoral phlegmasia that developed over cervical cancer radiation therapy induced DVT, was successfully resolved by clot removal. Extracting venous thrombus at the onset, while still as unorganized masses, preserves ambulation and prevents post-thrombotic syndrome development, an improvement of quality of life especially significant for oncologic patients with limited life-expectancy. Presentation of case A 34 years old female, with history of stage 3 cervical cancer following radiation therapy, was admitted in regards to left lower limb painful pitting oedema with cramps. Doppler scan revealed a left ileofemoral DVT. She was set on LMWH, but on fourth day of warfarin co-administration, phlegmasia cerulea dolens developed. An emergency venous thrombectomy with fasciotomy was performed. Postoperatively, dry foot gangrene developed, which dictated transmetatarsal amputation. The patient was discharged after 2 months of inpatient treatment, preserving ambulation. Discussion Venous thrombectomy (with fasciotomy) in oncologic phlegmasia, ± serial debridement, becomes an attractive opportunity for limb salvage when feasible at acute presentation, available in a limited resource setting. Conclusion Due to severe procoagulant/anticoagulant balance disturbances in cancer patients’ warfarin-bridged for DVT, phlegmasia onset should not defer surgical approach, unless a rapid response to conservative treatment.

Introduction: We report a unique association of an ancient Indian custom of postdelivery mother roasting and postpartum psychosis responsible for the causation of major burns. Materials and Methods: A 20-year-old postpartum female reported with 40% second- and third-degree total body surface area burns. The combination of the ancient Indian custom of mother roasting and postpartum psychosis led to these major burns. The conventional treatment of burns in the form of IV fluids, antibiotics, and dressings with silver sulfadiazine creams was carried out. The psychiatrist was consulted, and the antipsychotic medicines were started for an altered behavior. One month after the burns, she developed deep-vein thrombosis with venous gangrene of the left leg for which she required a below-knee amputation. She required 45 days of hospitalization and six surgical procedures in the form of debridement and split-thickness skin grafting. Problems such as hypotension, noncooperation due to the wild swing in the moods were overcome by proper fluid and electrolyte management, an adjustment in antipsychotic medicines, appropriate postoperative care, and chest physiotherapy. Results: One year of follow-up showed good stable scars. At present, she can perform all domestic as well as labor work on the farm, with the help of a below-knee prosthesis. There is no element of psychotic behavior at present. Conclusion: This case report sheds light on an ancient Indian custom of mother roasting and postpartum psychosis and its dangers in contracting severe burn injuries. Challenges posed by postpartum psychosis in the treatment of burns have been discussed.

Phlegmasia dolens is a rare form of massive venous thrombosis of the lower extremities that is associated with a high degree of morbidity, including venous gangrene, compartment type syndrome, and arterial compromise. We report the sonographic findings in a patient who presented with phlegmasia dolens.

INTRODUCTIONPhlegmasia caerulea dolens (PCD) is a clinical syndrome caused by venous obstruction leading to peripheral limb ischaemia. It can ultimately lead to venous gangrene, amputation or death in 25% of cases.PRESENTATION OF CASEA 52-year-old man with a background of myeloma developed PCD secondary to an obstructing plasmacytoma and left femoral vein deep vein thrombosis (DVT). These were treated with combined radiotherapy and anticoagulation, with resolution of the patient's symptoms. His recovery was complicated by the development of heparin-induced thrombocytopenia (HIT) and cutaneous vasculitis.DISCUSSIONBoth plasmacytoma and DVT are recognised complications of myeloma. This is, to our knowledge, the first description of these phenomena in combination causing PCD. The combination of venous stasis from the obstructing plasmacytoma and hypercoagulability from the underlying myeloma may have contributed to clot formation. A multifaceted treatment approach was required which aimed at improving venous flow via radiotherapy to the plasmacytoma and dissolving the obstructing clot with anticoagulant therapy.CONCLUSIONPCD has a high mortality and morbidity. Recognition is important to avoid an incorrect diagnosis of arterial occlusion and inappropriate surgical intervention. Treatment must be focused on removing the offending causes.

Venous gangrene is a rare complication of deep venous thrombosis. It is certain from review of literature that there is a significant causative relationship between malignant disease and venous gangrene. Data from the National hospital discharge survey from 1979 to 2006 showed that 0.43% of patients with deep venous thrombosis had gangrene, while 1.39% patients with gangrene had deep venous thrombosis. Toes and fingers are frequent site of venous gangrene in patients with massive deep venous thrombosis, as evident by review of literature. A possible explanation for this occurrence can be the fact that because of the scarcity of subcutaneous fat and the small spaces of fingers and toes, massive edema can generate large compressive forces; these forces may have a compressive effect on the arterioles, which may contribute to the development of venous gangrene. Lower extremities develop venous gangrene more commonly than upper extremities. The condition has an extremely high rate of mortality either from pulmonary embolism or from the serious underlying disease, such as neoplasms.

A 52 year old diabetic female with obstructive jaundice due to cholangiocarcinoma developed recurrent deep venous thrombosis and venous gangrene (phlegmasia caerulia dolens). Carcinomatosis is the usual underlying cause of this rare form of gangrene and has a high mortality. It is important to remember that diabetic subjects can develop ‘non-diabetic’ gangrene, and other causes should be considered depending upon the clinical presentation. Copyright © 2002 John Wiley & Sons, Ltd.

We report the unusual case of a 60-year-old-man presenting with left lower limb venous gangrene caused by an aorto-caval fistula. There was associated bilateral lower limb and scrotal oedema. In this case …

Publisher Summary This chapter describes the diagnosis of deep vein thrombosis (DVT). The clinical presentation of DVT can range from silent, with no symptoms or physical findings, to phlegmasiacerula dolens and venous gangrene. It presents a brief overview of the currently available technologies that continue to evolve and improve. The extent of thrombus in superficial veins usually extends further than is evident clinically, and in up to one-third of the cases, the thrombus will eventually extend into the deep system via the saphenofemoral junction or communicating veins. It is well documented that the clinical diagnosis of lower-limb DVT is unreliable. The traditional gold standard of objective DVT testing is ascending contrast phlebography. Compared to autopsy findings, it has 97% sensitivity and 95% specificity. The test, however, is costly, invasive, uncomfortable, and associated with definite risks. Fortunately, a number of methodologies available can objectively rule in or rule out the presence of DVT with accuracies very close to the gold standard of conventional contrast phlebography. They are also less invasive, safer, and usually, less costly. The limitations and shortcomings of the present-day testing methods should be viewed as challenges and not barriers to improving patient care.

El sindrome de Trousseau engloba una amplia variedad de trastornos de la coagulacion, siendo los fenomenos tromboticos migratorios los principales trastornos asociados. El tratamiento de esta situacion es dificil. Ademas, la gangrena venosa constituye un estadio final letal nada frecuente, de particular dramatismo y angustia para el paciente. Su tratamiento resulta desesperanzador.

A case of an older patient with developing venous gangrene of the left upper extremity and contraindications to systemic thrombolytic therapy are presented. Intraarterial application of a lytic agent was successfully applied. It is concluded that, in selected high-risk patients with developing venous gangrene and failed anticoagulation therapy, the intraarterial application of a thrombolytic agent may be the therapy of choice.

There are few reported cases of acute portal vein thrombosis presenting as an acute abdomen in adolescent age group. Most published series concern chronic extrahepatic portal vein thrombosis. Acute portal vein thrombosis is rare, but can develop into serious complications. Hence, prompt diagnosis and heparinization can prevent the development of lethal complications such as venous gangrene of the bowel and portal hypertension.

Summary Two cases of phlegmasia caerulea dolens with peripheral venous gangrene treated with streptokinase are presented. Both patients had excellent results, beyond expectation. The literature is reviewed and the symptomatology, aetiology, pathogenesis and current thoughts on treatment are discussed.

Thrombosis of the subclavian and axillary vein is a rare entity. Venous gangrene of the upper extremity is even more rare. A case of a 71-year-old man with poorly differentiated squamous cell carcinoma who developed venous gangrene of the right hand has been presented.