Experience in the management of sigmoid sinus thrombophlebitis secondary to middle ear cholesteatoma.

OBJECTIVE: To discuss the management of sigmoid sinus thrombophlebitis secondary to middle ear cholesteatoma. METHODS: We retrospectively analyzed all cases of sigmoid sinus thrombophlebitis caused by middle ear cholesteatoma over a period of 7 years. 7 male and 2 female patients, ranging in age from 9 to 66 years, were diagnosed with sigmoid sinus thrombophlebitis by clinical presentation and radiological examination. By executing a modified mastoidectomy and tympanoplasty (canal wall-down tympanoplasty) to entirely remove the cholesteatoma-like mastoid epithelium, all patients were effectively treated surgically without opening the sigmoid sinus. All patients were treated with broad-spectrum antibiotics, but no anticoagulants were used. RESULTS: 9 patients had otogenic symptoms such as ear pus, tympanic membrane perforation, and hearing loss. In the initial stage of the surgery, modified mastoidectomy and tympanoplasty were performed on 8 of the 9 patients. 1 patient with a brain abscess underwent puncturing (drainage of the abscess) to relieve cranial pressure, and 4 months later, a modified mastoidectomy and tympanoplasty were carried out. Following surgery and medication, the clinical symptoms of every patient improved. After the follow-up of 6 months to 7 years, 3 patients were re-examined for MRV and showed partial sigmoid sinus recovery with recanalization. 4 months following middle ear surgery, the extent of a patient's brain abscess lesions was significantly reduced. 1 patient experienced facial paralysis after surgery and recovered in 3 months. None of the patients had a secondary illness, an infection, or an abscess in a distant organ. CONCLUSION: The key to a better prognosis is an adequate course of perioperative antibiotic medication coupled with surgical treatment. A stable sigmoid sinus thrombus can remain for a long time after middle ear lesions have been removed, and it is less likely to cause infection and abscesses in the distant organs. The restoration of middle ear ventilation is facilitated by tympanoplasty. It is important to work more closely with multidisciplinary teams such as neurology and neurosurgery when deciding whether to perform lateral sinusotomies to remove thrombus or whether to administer anticoagulation.

Flegmasia cerúlea dolorosa en paciente con trombocitopenia inmune primaria: un gran reto terapéutico / Phlegmasia cerulea dolorosa and primary immune thrombocytopenia: a therapeutic challenge

Introducción: la flegmasia cerúlea dolorosa resulta de una trombosis venosa masiva aguda que provoca unaobstrucción del drenaje venoso de una extremidad y se asocia con un alto grado de morbilidad.Caso clínico: presentamos el caso de un paciente con fl egmasia cerúlea dolorosa y múltiples factores de riesgopara desarrollarla, quien fue llevado a trombólisis dirigida por catéter, con lo que se logró salvar la extremidad.Discusión: la fl egmasia cerúlea dolorosa es una entidad poco frecuente que puede progresar de manera rápiday comprometer la vitalidad de la extremidad afectada o llevar a desenlaces fatales, por lo que requiere una prontasospecha y una intervención emergente. La terapia antitrombótica sigue siendo el manejo de elección.(AU)

Introduction: phlegmasia cerulea dolorosa results from acute massive venous thrombosis that causes obstructionof the venous drainage of an extremity, and it’s associated with a high morbidity.Case report: we present the case of a patient with phlegmasia cerulea dolorosa and multiple risk factors fordeveloping it, who was taken to catheter-directed thrombolysis successfully.Discussion: phlegmasia cerulea dolorosathis is a rare entity that can progress rapidly and compromise the vitalityof the limb or lead to fatal outcomes, which requires early suspicion and emergency intervention. Antithrombotictherapy continues to be the ideal treatment.(AU)

Mondor's penile disease requiring thrombectomy: A case report and literature review.

The thrombophlebitis of the superficial dorsal vein of the penis, called Mondor's penile disease (PMD), is a condition with a low incidence worldwide. In general, it is considered a self-limited disease that usually resolves with conservative management and very rarely requires surgical intervention. We report the case of a 41-year-old patient, who presented PMD which persists after medical treatment with nonsteroidal antiinflammatory drug and low molecular weight heparin. Surgery was decided and thrombectomy plus resection of the superficial penile vein was performed with satisfactory results. A review of the literature is presented, focusing on the limited available evidence of surgical management.

A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy.

Coronavirus disease 2019 (COVID-19) has been widely reported to be associated with increased risk of Venous Thromboembolism, both deep vein thrombosis (DVT) and pulmonary embolism. A rare and extreme manifestation of DVT is Phlegmasia cerulea dolens, characterized by poor tissue perfusion due to marked limb swelling which can progress to limb and life-threatening venous gangrene. We report the case of a 53-year-old man with severe SARS-CoV2 pneumonia who developed acute iliofemoral DVT leading to acute limb ischemia due to Phlegmasia cerulea dolens. The patient underwent successful emergent fasciotomy and mechanical thrombectomy with removal of extensive thrombus burden and restoration of normal venous circulation. Our case highlights the importance of clinical vigilance and early implementation of therapeutic interventions to avoid adverse outcomes in patients who develop SARS-CoV2 induced Venous Thromboembolism complications.

Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report.

BACKGROUND: COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both. CASE PRESENTATION: A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated. CONCLUSIONS: This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

Flegmasia cerúlea dolorosa y gangrena venosa asociada a infección por SARS-CoV-2: reporte de caso y revisión de la literatura / Flegmasia cerúlea dolens and venous gangrena associated with infection by SARS-CoV-2: case report and literature review

La flegmasia cerúlea dolorosa (FCD) y la gangrena venosa son las manifestaciones más graves de la trombosis venosa profunda aguda (TVP). Se presenta el caso de una mujer de 64 años que ingresó en el servicio de emergencias por dolor de la extremidad inferior izquierda y edema localizado en el pie, con diagnóstico de gangrena venosa tras los análisis correspondientes de clínica, laboratorio e imagen. Ante la evolución tórpida se realizaron fasciotomías, con mejoría evidente el cuadro. Al fi liar la causa de este evento, se adjudica a la infección por SARS-CoV-2 como desencadenante de esta gangrena venosa

Cerulean phlegmasy dolens (CDF) and venous gangrene are the most serious manifestations of acute deep vein thrombosis (DVT ). We present the case of a 64-year-old woman who was admitted to the emergency service for pain in the left lower limb and localized edema in the foot with a diagnosis of venous gangrene after the corresponding clinical, laboratory and imaging analysis. Given the torpid evolution, fasciotomies were performed with evident improvement in the picture. When fi ling the cause of this event, it is attributed to the infection by SARS-CoV-2 as the trigger for this venous gangrene

Management of Phlegmasia Cerulea Dolens with Percutaneous Mechanical Thrombectomy.

Advanced cases of phlegmasia cerulea dolens (PCD) with absent pedal pulses, sensory/motor deficits, and/or venous gangrene likely require more rapid restoration of flow compared to cases without these factors to prevent progression and associated morbidity/mortality. We present a case of PCD with absent pedal pulses and sensory deficit managed successfully with emergent percutaneous mechanical thrombectomy using Inari ClotTriever (Inari Medical, Irvine, CA) with immediate clinical resolution, including restoration of pedal pulses ~ 45 min after thrombectomy. Percutaneous mechanical thrombectomy with the ClotTriever device has the ability to immediately restore venous flow reversing the pathophysiology of PCD in a short time period similar to surgical embolectomy and may be an alternative treatment strategy in patients with phlegmasia cerulea dolens of high severity.

ASSESSMENT OF QUALITY OF LIFE IN PATIENTS AFTER THE TREATMENT OF ACUTE ASCENDING THROMBOPHLEBITIS OF THE GREAT SAPHENOUS VEIN WITH OF HIGH-FREQUENCY ENDOVENOUS WELDING.

Acute thrombophlebitis of the superficial veins is an urgent problem as it can spread to the deep veins with the subsequent development of pulmonary embolism. The social implications of varicotrombophlebitis are the long-term disability of most patients up to complete disability, so finding the least invasive methods of correction of the discussed disease is a pressing issue of modern phlebology. The research objective is to carry out a comparative analysis of the quality of life of patients with acute ascending thrombophlebitis of the great sapheneous vein after treatment with high-frequency endovenous welding and standard phlebectomy. The results of treatment of 63 patients with acute ascending thrombophlebitis of great saphenous vein (GSV) with III and IV class of thrombophlebitis, who were hospitalized in the surgical wards of the Municipal Clinical Hospital No. 8 of Kyiv from 2017 to 2018, were analyzed. Welding of the thrombotic vein segment was performed using an endovenous welding catheter (WC). Quality of life (QOL) results were assessed using CIVIQ2 (Chronic Venous Insufficiency Questionnaire). According to ultrasound duplex scanning, complete vein ablation occurred in 97.22% of patients after endovenous welding (EW) of thrombotic GSV. In all patients of Group I already on day 2, the total rate of QOL by all factors (pain, physical, social, psychological) significantly (p<0.05) exceeded the presurgery values and was 79.3%, when before treatment this indicator was 4.3% higher. At follow-up, QOL values continued to improve over all observation periods compared to the previous term (p <0.05). Quality of life restriction in connection with pain, social and psychological factors after EW decreased 2.1 times(p<0.05), when in control group patients - only 1.2 times. The revealed advantages of the method of high-frequency endovenous welding by all indicators of quality of life over standard phlebectomy allow recommending this method for wide practical application.

[Endovascular treatment of acute thrombophlebitis of the lower extremities in patients with varicose veins]. / Éndovaskuliarnoe lechenie ostrogo tromboflebita ven nizhnikh konechnostei u patsientov s varikoznoi bolezn'iu.

OBJECTIVE: To study the results of endovenous laser obliteration (EVLO) for acute thrombophlebitis of saphenous veins of the lower extremities. MATERIAL AND METHODS: There were 57 patients (39 (68%) men and 18 (32%) women), mean age of patients was 54±20 years (range 34-74) with acute ascending thrombophlebitis of varicose superficial veins of the lower extremities (type I and II). EVLO of great saphenous vein was performed in 48 cases, small saphenous vein - in 9 patients. All EVLO procedures were carried out in outpatient fashion without hospitalization to the hospital. RESULTS: Complete obliteration of the target vein confirmed by ultrasound was observed in all patients the next day after surgery. Smooth course in long-term period (up to 1 year) was also noted in all patients. Recanalization of previously obliterated venous segment was absent. CONCLUSION: EVLO a safe and reliable alternative to traditional surgical approach for acute ascending thrombophlebitis. This technique is followed by reduced incidence of recurrent thrombophlebitis, no injuries typical for conventional surgery, minimal postoperative hospital-stay and pain syndrome. The procedure is characterized by minimal trauma, favorable cosmetic result and does not require hospitalization to specialized hospitals. EVLO for thrombophlebitis of varicose veins results high economic benefits due to minimally invasive simultaneous treatment of varicose veins and thrombophlebitis with small incidence of recurrences and complications.

Septic superficial thrombophlebitis in Klippel-Trenaunay syndrome.

This is a rare case of a young patient with Klippel-Trenaunay syndrome that presented with extensive septic superficial thrombophlebitis of the lower extremity. Treatment included intravenous antibiotics based on cultures, anticoagulant therapy as well as surgical removal of thrombi.

[Prospective comparative study of remote results of surgical treatment of patients with varicothrombophlebitis]. / Prospektivnoe sravnitel'noe issledovanie otdalennykh rezul'tatov khirurgicheskogo lecheniia bol'nykh varikotromboflebitom.

The authors examined the effect of the presence of undifferentiated connective tissue dysplasia (UCTD) on the clinical course of lower-limb varicose veins (LLVV) and acute varicothrombophlebitis (AVTP) in patients after the Troyanov-Trendelenburg operation. We carried out a prospective comparative study of the remote results during three years after the Troyanov-Trendelenburg operation in a total of 132 patients suffering from AVTP. The Study Group included 67 patients found to have more than four phenotypic traits of UCTD, thus suggesting the presence of UCTD. The Comparison Group consisted of 65 patients with no signs of UCTD. During three-year follow up, relapses of AVTP were diagnosed in 22 (32.8%) patients of the Study Group and in 5 (7.7%) patients of the Comparison Group (p<0.01). In four (6.0%) patients with UCTD, the thrombus propagated to the perforating veins of the crus, new danger of pulmonary embolism arose, and emergency phlebectomy was required. Thrombosis of the femoral vein was revealed in eight (11.9%) patients of the Study Group, and being free-floating in two (3.0%) of them, it was the cause of pulmonary embolism. They were subjected to plication of the external iliac vein. No thromboses of deep veins were revealed in the Comparison Group patients. Phlebectomy was performed in 57 (85.1%) patients of the Study Group and in 14 (21.5%) patients of the Comparison Group (p<0.01) due to remaining vertical and horizontal pathological venous reflux. Fifty-one (78.5%) patients of the Comparison Group six months after the Troyanov-Trendelenburg operation were found to have spontaneous restoration of the functional competence of the valvular apparatus of the perforating veins with elimination of the horizontal venous reflux, which predetermined regression of clinical manifestations of varicose veins, with no phlebectomy required. A conclusion drawn is that the clinical course of LLVV on the background of UCTD after the Troyanov-Trendelenburg operation is distinguished by predisposition to progression of chronic venous insufficiency and is characterised by a relapsing pattern of AVTP. Therefore, surgical policy, as well as medicamentous treatment after disconnection of the saphenofemoral junction in patients with AVTP should be decided upon with due regard for the phenotypic signs characterising UCTD.

Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature.

We describe the cases of 2 patients who had septic thrombophlebitis and were successfully managed with endovascular thrombectomy. Patient A developed septic thrombophlebitis of the inferior vena cava after several retroperitoneal resections for metastatic renal cell carcinoma. The thrombus was successfully removed via endovascular mechanical balloon thrombectomy. Patient B was a patient with pancreatic adenocarcinoma involving the portal vein who developed a septic inferior vena cava thrombus extending from the level and beyond the renal veins, for which she underwent endovascular thrombectomy. We argue that this approach is safe and feasible. It should be considered as a supplemental treatment modality for select decompensating patients who require lifesaving interventions and have contraindications to traditional management of surgical thrombectomy or excision of the involved venous segment.

Treatment for superficial thrombophlebitis of the leg.

BACKGROUND: The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the third update of a review first published in 2007. OBJECTIVES: To assess the efficacy and safety of topical, medical, and surgical treatments for ST of the leg in improving local symptoms and decreasing thromboembolic complications. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (March 2017), CENTRAL (2017, Issue 2), and trials registries (March 2017). We handsearched the reference lists of relevant papers and conference proceedings. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included people with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in a superficial vein. DATA COLLECTION AND ANALYSIS: Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We identified three additional trials (613 participants), therefore this update considered 33 studies involving 7296 people with ST of the legs. Treatment included fondaparinux; rivaroxaban; low molecular weight heparin (LMWH); unfractionated heparin (UFH); non-steroidal anti-inflammatory drugs (NSAIDs); compression stockings; and topical, intramuscular, or intravenous treatment to surgical interventions such as thrombectomy or ligation. Only a minority of trials compared treatment with placebo rather than an alternative treatment and many studies were small and of poor quality. Pooling of the data was possible for few outcomes, and none were part of a placebo-controlled trial. In one large, placebo-controlled RCT of 3002 participants, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.04 to 0.50; moderate-quality evidence), ST extension (RR 0.08, 95% CI 0.03 to 0.22; moderate-quality evidence), and ST recurrence (RR 0.21, 95% CI 0.08 to 0.54; moderate-quality evidence) relative to placebo. Major bleeding was infrequent in both groups with very wide CIs around risk estimate (RR 0.99, 95% CI 0.06 to 15.86; moderate-quality evidence). In one RCT on 472 high-risk participants with ST, fondaparinux was associated with a non-significant reduction of symptomatic VTE compared to rivaroxaban 10 mg (RR 0.33, 95% CI 0.03 to 3.18; low-quality evidence). There were no major bleeding events in either group (low-quality evidence). In another placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (prophylactic: RR 0.44, 95% CI 0.26 to 0.74; therapeutic: RR 0.46, 95% CI 0.27 to 0.77) and NSAIDs (RR 0.46, 95% CI 0.27 to 0.78) reduced the extension (low-quality evidence) and recurrence of ST (low-quality evidence) in comparison to placebo, with no significant effects on symptomatic VTE (low-quality evidence) or major bleeding (low-quality evidence). Overall, topical treatments improved local symptoms compared with placebo, but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatments, topical treatments, or surgery did not report VTE, ST progression, adverse events, or treatment adverse effects. AUTHORS' CONCLUSIONS: Prophylactic dose fondaparinux given for 45 days appears to be a valid therapeutic option for ST of the legs for most people. The evidence on topical treatment or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE. Further research is needed to assess the role of rivaroxaban and other direct oral factor-X or thrombin inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment in people at various risk of recurrence; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.

Necrotizing Lip Infection Causing Septic Thrombophlebitis of the Neck: A Rare Variant of Lemierre Syndrome.

Lemierre syndrome is an uncommon condition in which internal jugular vein thrombosis presents after recent oropharyngeal infection. Frequently, this is accompanied by septic emboli. This report outlines a variant of this disease process, with septic thrombophlebitis of the neck associated with a necrotizing skin infection of the lower lip and chin. A 25-year-old man with lower lip and chin swelling, initially managed with intravenous antibiotics, progressed to the development of a left facial vein thrombus, septic emboli to the lungs, and a necrotizing lower lip and chin infection that was managed with debridement, thrombectomy, and prolonged hemodynamic and pulmonary support. A necrotizing skin infection with thrombus of the jugular system and septic emboli is a very rare variant of Lemierre syndrome. Early recognition of an infection with septic emboli and/or necrotizing pathobiological findings allows for prompt antibiotic and surgical therapy, minimizing the mortality of these potentially lethal infections.

Phlegmasia Cerulea Dolens as an Unusual Presentation of Ruptured Abdominal Aortic Aneurysm into the Inferior Vena Cava.

The aim of this case study is to report a case of unusual manifestation of ruptured abdominal aortic aneurysm (AAA) involving an aortocaval fistula (ACF) as phlegmasia cerulea dolens (PCD). A 58-year-old male presented with acute signs of PCD of the right lower limb, confirmed on duplex ultrasonography. Computed tomography angiography revealed a 65-mm ruptured AAA with a large ACF. Successful emergent surgical repair was performed, using implantation of an aortobi-iliac graft with primary closure of the fistula and associated venous thrombectomy. PCD revealing a ruptured AAA with ACF is rare. Knowledge of this original entity might be the most important factor on the outcome.

[PROPHYLAXIS OF THROMBOEMBOLIC COMPLICATIONS IN TRANSFASCIAL THROMBOSIS OF THE LOWER EXTREMITIES].

Results of examination and treatment of 339 patients, suffering an acute varicothrombophlebitis, complicated by transfascial thrombosis, were analyzed. Indications for surgical prophylaxis of pulmonary thromboembolism in transfascial thrombosis in a system of vena cava inferior were studied. After the operation in all the patients, while presence of transfascial thrombosis, not taking into account the operation radicalism, the treatment was prescribed, similar to that for the deep veins thrombosis. In the deep veins thrombosis, combined with superficial varicothrombophlebitis , an access for excision of a small subcutaneous vein of lower extremity must be differentiated, depending on spreading of thrombotic occlusion and localization of the calf veins inflowing place. Introduction of active surgical tactic in presence of floating thrombus in the ankle­popliteal venous segment secures conduction of effective prophylaxis of pulmonary thromboembolism