Bianchi A, Pozza S, Giovannacci L, van den Berg Jos C
Department of Visceral and Vascular Surgery, Ospedale Regionale di Lugano-CH, Switzerland.
Department of Interventional Radiology, Ospedale Regionale di Lugano-CH, Switzerland.
Case Rep Vasc Med. 2020 Feb 27;2020:2176848. doi: 10.1155/2020/2176848. eCollection 2020.
No clear guidelines exist for the management of phlegmasia cerulea dolens. This case report shows how a hybrid approach might be successful. It also shows how rare pathologies can combine to create a life- and limb-threatening condition. . A 75-year-old man, known for nephrotic syndrome currently under investigation, presented to the emergency department with a 24-hour history of left leg swelling followed by intense pain. The left lower limb showed a phlegmasia cerulean dolens. Renal function, coagulation profile, and inflammatory parameters were normal; D-Dimers 5,6 mg/L. The CT scan showed juxtarenal thrombosis of the hypoplastic IVC, involving both renal veins, reaching the left iliac-femoral-popliteal axis, with collateralization to the pelvic and mesenteric veins, associated with bilateral segmental pulmonary embolisms. A suspected left breast nodule was also found. Intravenous heparin was immediately administered, and urgent hybrid procedure with surgical thrombectomy and venous angiography and thromboaspiration, liberating the iliolumbar collaterals, was performed. A lateral leg fasciotomy was mandatory due to the phlegmasia cerulea. Postoperative Doppler US showed a good venous compressibility of the left leg. Thrombophilia screening was negative. The breast nodule was biopsied showing an invasive ductal carcinoma. The patient was discharged with oral rivaroxaban and indication for left mastectomy and oncological therapy with aromatase inhibitors.
This case highlights the dramatic consequence of different risk factors for venous thromboembolism as cancer and nephrotic syndrome in a patient with hypoplasia of the inferior cava vein. Venous thromboaspiration has been used in order to timely recanalize important collaterals. Phlegmasia cerulea dolens was resolved after the procedure and lateral calf fasciotomy. Further evidence is needed to clearly define the role of venous thromboaspiration in the treatment of complex proximal deep venous thrombosis of the lower extremity.
对于股青肿的治疗，目前尚无明确的指南。本病例报告展示了一种联合治疗方法如何取得成功。它还展示了罕见的病理情况如何相互结合，导致危及生命和肢体的状况。一名75岁男性，因肾病综合征正在接受检查，因左腿肿胀24小时并伴有剧痛就诊于急诊科。左下肢呈现股青肿。肾功能、凝血指标及炎症参数均正常；D - 二聚体为5.6mg/L。CT扫描显示发育不全的下腔静脉肾旁血栓形成，累及双侧肾静脉，延伸至左髂股 - 腘静脉轴，并伴有盆腔和肠系膜静脉的侧支循环形成，同时合并双侧节段性肺栓塞。还发现了一个疑似左侧乳腺结节。立即给予静脉注射肝素，并紧急进行了联合手术，包括手术取栓、静脉血管造影及血栓抽吸，松解了髂腰侧支循环。由于股青肿，进行了小腿外侧筋膜切开术。术后多普勒超声显示左腿静脉具有良好的可压缩性。血栓形成倾向筛查为阴性。对乳腺结节进行活检，结果显示为浸润性导管癌。患者出院时口服利伐沙班，并被建议进行左乳切除术及使用芳香化酶抑制剂进行肿瘤治疗。
本病例突出了在一名下腔静脉发育不全患者中，癌症和肾病综合征等不同静脉血栓栓塞风险因素所带来的严重后果。采用静脉血栓抽吸术以便及时再通重要的侧支循环。术后股青肿及小腿外侧筋膜切开术后均得到缓解。需要更多证据来明确静脉血栓抽吸术在治疗复杂的下肢近端深静脉血栓形成中的作用。
