December 12, 2008

Percutaneous Thrombolysis for Phlegmasia Cerulea Dolens

Luke S. Erdoes, MD, Jessica B. Ezell, Stuart I. Myers, MD, L Richard Sprouse, Jr., MD, Christopher J. Lesar, MD.
University of Tennessee, Chattanooga, TN, USA.

Objective: Phlegmasia cerulea dolens (PCD) is a limb threatening condition. Open thrombectomy is a morbid procedure. We examine if percutaneous treatment of PCD is a better way to treat this condition.
Methods: Between May 2005 and August 2008 we treated 19 patients who presented with lower extremity PCD and were candidates for thrombolysis. Diagnosis of PCD was by clinical exam and duplex ultrasound. All patients underwent initial inferior vena cava filter placement. Catheter access to the deep venous system was obtained via the popliteal vein. Therapy utilized pulse spray thrombolysis with tissue plasminogen activator (TPA) delivered by the Angiojet thrombectomy system. Infusion catheters and adjunctive percutaneous techniques were used as indicated. Post-operatively, all patients were treated with systemic anticoagulation and compression hose and were followed at intervals. Limbs were graded according to the CEAP classification.
Results: Nineteen patients (11 men) were treated with a mean age of 52.2 years. 8 patients were diagnosed with hypercoagulable states, 4 with May Thurner syndrome, 3 had a history of cancer, one post colon resection, one following acute myocardial infarction, and one post femoral vein puncture. All 19 patients had resolution of the PCD without need for open surgery. The initial TPA dose was 19.5 +/- 1.4 mgs with pulse spray Angiojet thrombolysis. Infusion catheters were required in 17 patients and utilized for 36 +/-7 hours until complete thrombolysis. Venous angioplasty was necessary in 13 patients with 9 of these requiring venous stents. One patient required above knee amputation despite successful treatment of her PCD. There were 3 deaths unrelated to thrombolysis. Mean follow-up was 13 months. All patients demonstrated no or minimal residual thrombus and intact valvular function. All venous stents were patent. Patients had a mean C score of 2.4.
Conclusion: Percutaneous treatment of PCD produced excellent results with minimal morbidity, and should be considered for all patients with this condition who may undergo thrombolysis.

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