Massive DVT.
The most important complication of a DVT is of course pulmonary embolism. However less common complications can be devastating as well. Cerulea alba dolens (CAD, “milk leg”), cerulea phlegmasia dolens (CPD) and venous gangrene are a spectrum of the same disorder. The pathophysiology to all three of these conditions is that a massive DVT significantly compromises venous outflow. In CAD, only the major venous system is involved, sparing the collateral circulation, making the leg look swollen but not discolored (but rather white and doughy in appearance). This may occur in the third trimester of pregnancy. It almost always preceded CPD, in which the thrombosis does involve the collateral venous system, leading to massive congestion and fluid sequestration. The leg is more swollen, cyanotic, and painful (although in our case the patient had no pain). Pulses may still be present, but may sometime be difficult to appreciate in the setting of significant edema. When the capillary system is affected, venous gangrene results, with rapid rise of compartmental pressures and arterial insufficiency. Patients may be in shock due to significant fluid sequestration.
The same risk factors that predisposed patients for DVT are responsible for CAD/CPD as well. However malignancy is identified in 20-40% of the patients. Some other risk factors include hypercoagulable states, surgery, trauma, ulcerative colitis, heart failure, mitral valve stenosis, vena caval filter insertion, and May-Thurner syndrome. Lower extremities are more commonly involved, with left being more common than right lower extremity.
The diagnosis is made clinically, but ultrasound is often ordered to confirm the diagnosis. Venogram is the gold standard test for the diagnosis. However, the diagnostic studies should not impede the start of anticoagulation and prompt consultation with a vascular surgeon.
Initial medical therapy is with IV heparin and IV fluid support if there is hypotension. Heparin should be instituted in all cases since thrombectomy cannot open the small venules that are affected in venous gangrene, and it does not prevent valvular incompetence or postphlebitic syndrome. In more severe cases, and in those with evidence of ischemia and gangrene, the addition of surgical treatment is usually necessary, involving thrombectomy and possible fasciotomy.
