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Venous gangrene
From WikEM
Contents
Background
- Massive iliofemoral or IVC occlusion with patent arteries
- Extensive vascular congestion and venous ischemia
- Involves superficial collateral veins
- 40-60% of phlegmasia cerulea dolens with capillary involvement progress to venous gangrene
Risk Factors
- Age 50-60s
- Malignancy (over half)
- Thrombophlebitis migrans
- Acquired hemolytic anemia due to cold-antibodies
- Typical risk factors for DVT(pregnancy, surgery, trauma, hypercoagulable syndrome)
- Idiopathic
Clinical Features
- Limb pain
- Severe edema
- Cyanosis
- Blistering and extravasation
- Purplish black well-circumscribed areas
- Superficial gangrene and necrosis
- Arterial patency
- Not reversible (vs. phlegmasia cerulea dolens and alba dolens are)
- Fluid sequestration and circulatory shock
Differential Diagnosis
Clinical Spectrum of Venous thromboembolism
- Deep venous thrombosis (uncomplicated)
- Phlegmasia alba dolens
- Phlegmasia cerulea dolens
- Venous gangrene
- Pulmonary embolism
- Isolated distal deep venous thrombosis
Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]
Others
- Cellulitis
- Lymphedema
- Venous valvular insufficiency
- Superficial thrombophlebitis
- Arterial embolism
- Diabetic ulcer
- Wet/gas gangrene
Evaluation
- Clinical diagnosis
- Duplex US
- Contrast venography
- MRV
Management
- Interventional radiology consult for emergent catheter-directed thrombolysis
- Vascular surgery consult for thrombectomy
- Steep limb elevation
- Fluid resuscitation (PRBC)
- Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
- Thrombolytic: Alteplase (1mg/min to total of 50mg) distal to thrombus
Disposition
- Admit
See Also
External Links
References
- ↑ Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
- ↑ Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
