What is the role of surgery in the treatment of phlegmasia alba dolens (PAD) and phlegmasia cerulea dolens (PCD)?

Updated: Aug 13, 2018
  • Author: Cassius Iyad Ochoa Chaar, MD, MS, FACS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Answer

Catheter-directed thrombolytic therapy is the mainstay of therapy for the extensive DVT that is usually associated with phlegmasia. It is minimally invasive, effective, and safe, as shown in a 2012 systematic review of the literature. [14]

The patient is kept on heparin drip and brought to an angiography suite or a hybrid operating room. Under ultrasonographic guidance, the popliteal vein or a tibial vein is accessed and a 6-French sheath placed. The thrombus is crossed with a 0.035-in. wire, a multihole infusion catheter is placed in the vein, and an infusion of alteplase is started.

The patient is transferred to an intensive care unit (ICU) and typically receives alteplase infusion over a period of 2-4 days. A low-dose heparin drip is given at constant rate through the access sheath to prevent thrombosis around the sheath. The patient goes back for angiographic checks on a daily basis.

A combination of pharmacomechanical thrombolysis using devices that macerate and aspirate the clot (eg, AngioJet [Boston Scientific, Marlborough, MA] or Trellis [Covidien, Minneapolis, MN]) or balloon angioplasty to break down the thrombus is performed. Venous occlusive lesions or areas of stenosis can be treated with stenting after dissolution of the acute thrombus.

In patients with tissue compromise because of extensive thrombosis, a more aggressive approach using pharmacomechanical thrombolysis [9] or aspiration thrombectomy [5, 15] during the first angiogram can provide enough outflow to avoid progression of ischemia. Placement of an inferior vena cava (IVC) filter decreases the risk of iatrogenic PE during thrombolysis but has not been shown to affect survival. [16]


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