Outcomes of rheolytic thrombectomy in phlegmasia cerulea dolens.

OBJECTIVE: The purpose of this study was to assess the clinical features of phlegmasia cerulea dolens and present the treatment outcomes with rheolytic thrombectomy device. METHODS: From January 2014 and March 2019, 329 patients were diagnosed and hospitalized for acute iliofemoral deep vein thrombosis, and among those patients, seven patients diagnosed with lower extremity phlegmasia cerulea dolens were consecutively enrolled. Diagnosis of phlegmasia cerulea dolens was initially made on clinical findings followed by imaging with Doppler ultrasound. The rheolytic thrombectomy device was used in all patients with a combination of catheter-directed thrombolysis as an adjunctive therapy to facilitate more rapid thrombus clearance except for one patient who had a contraindication to the use of tissue plasminogen activator. RESULTS: Seven patients (four men, three women; median age, 63 years, range 52-68 years) were included. One patient had a relative contradiction to thrombolysis due to history of coronary artery bypass graft surgery; all other patients underwent pharmaco-mechanical thrombectomy with power pulse mode. The upper limit of 480 s was completed in all patients, and this time was not exceeded to prevent hemolysis-related complications. Six Fr catheters were used in four (57.1%) patients, and 8 Fr catheters were used in three patients (42.9%). Mean thrombolytic infusion duration was 28 ± 6.2 h for patients who received tissue plasminogen activator. After catheter-directed thrombolysis, total radiological success was achieved in two patients, and partial radiologic success was achieved in five patients; however, in all seven patients, clinical success was achieved. The mean duration for complete regression of cyanosis was 18.9 ± 8.1 h. Although no patients required blood replacement, mean decreases in hemoglobin and hematocrit were 2.7 ± 1.37 g/dl and 6.42 ± 4.47%, respectively. Acute kidney injury developed in three patients (42.9%). One patient required continuous renal replacement therapy. No cardiac complication was observed. One (14.3%) patient died of ventilator-related pneumonia on postprocedural day 10. The median duration of intensive care unit stay and hospital stay were 72 h (min-max: 24-264 h) and six days (min-max: 5-33 days), respectively. CONCLUSION: Rheolytic thrombectomy was less invasive and effective strategy for early stage phlegmasia cerulea dolens at creating rapid thrombus clearance to establish clinical success and facilitate more conservative management with catheter-directed thrombolysis.

Methicillin-Resistant Staphylococcus aureus Septic Internal Jugular Thrombophlebitis: Updates in the Etiology and Treatment of Lemierre's Syndrome.

BACKGROUND: Lemierre's syndrome is classically precipitated by oropharyngeal infections that progress to suppurative internal jugular vein thrombophlebitis via direct extension. Metastatic pneumonia from septic emboli is nearly universal and bacterial seeding frequently results in disseminated septic foci. Fusobacterium necrophorum is the most commonly reported etiologic agent, though methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen and a myriad of oropharyngeal flora must be covered until blood cultures return. Prompt identification is paramount to minimizing morbidity. Empiric treatment with antibiotics exhibiting predominantly anaerobic activity has been standard, but now may be insufficient, given an evolving microbial landscape. Anticoagulation continues to be debated. CASE REPORT: We describe an uncommon presentation of Lemierre's syndrome in a diabetic patient secondary to MRSA, where the only identifiable source of entry was atraumatic post-auricular cellulitis. Why Should an Emergency Physician Be Aware of This? Given the evolving landscape of organisms implicated in septic internal jugular thrombophlebitis, empiric treatment should entail consideration of MRSA. Patients at an elevated risk include those who are undomiciled or incarcerated, injection drug users, human immunodeficiency virus-positive, and have recently been hospitalized or completed a course of antibiotics. The existing evidence evaluating empiric anticoagulation is low-powered and retrospective and would benefit from randomized controlled trials. Although it does not appear valuable for most, those with thrombus extension, persistent bacteremia, or central venous thrombosis may benefit.

Thrombolysis for Management of Phlegmasia Cerulea Dolens in the First Trimester of Pregnancy.

BACKGROUND: Pregnancy is a hypercoagulable state associated with a fivefold increase in the risk of venous thromboembolism. Thrombolysis is the preferred level of care for patients with acute iliofemoral deep vein thrombosis (DVT); however, most studies exclude pregnant patients, highlighting the lack of data regarding the efficacy and safety of thrombolytic therapy for mother and fetus. METHODS: We describe the successful use of thrombolytic therapy in conjunction with ultrasound to remove a large ileofemoral DVT in a first-trimester patient with phlegmasia cerulea dolens. The procedure was performed safely for both mother and fetus. RESULTS: No radiation or contrast dye was used, and intravascular ultrasound confirmed patency of the entirety of the venous system. She delivered a healthy term baby after the procedure and had no further sequalae. CONCLUSION: Thrombolysis with intravascular ultrasound may be considered in first-trimester pregnant patients with threatened limb due to DVT.

Trauma on a Recently Augmented Breast as a Trigger for Mondor's Disease.

Mondor's disease is the eponym used to describe a self-limited phlebitis or thrombophlebitis of the superficial veins localized mainly on the thoracoabdominal area of the human body. Its clinical manifestation includes painful superficial cords causing skin retraction. This medical condition could be idiopathic, iatrogenic or a manifestation of underlying pathology such as breast cancer and seems to be more common than has been previously thought. The vast majority of the clinical studies and case reports to date focus on Mondor's disease as a disorder which is more or less directly related to a previous surgical intervention. In this case report, the author discusses the possible role of breast surgery as a predisposing factor only and the trauma on the operated breast as a trigger for onset and earlier manifestation of Mondor's disease. A special emphasis is put on the importance of trauma prevention in breast augmentation surgery, especially when maneuvers like postoperative massages are considered.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[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.

Surgical Thrombectomy and Simultaneous Stenting for Phlegmasia Cerulea Dolens Caused by Iliac Vein Occlusion.

BACKGROUND: Phlegmasia cerulea dolens (PCD) is a severe complication of deep veions thrombosis, and there are several treatment methods. This study aimed to investigate the clinical efficacy of surgical thrombectomy and simultaneous iliac vein stent implantation for the treatment of PCD caused by iliac vein occlusion. PURPOSE: This study aimed to investigate the clinical efficacy of surgical thrombectomy and simultaneous iliac vein stent implantation for the treatment of phlegmasia cerulea dolens (PCD) caused by iliac vein occlusion. METHODS: From February 2014 to December 2016, 5 patients with secondary PCD complicated with iliac vein occlusion were treated in our center. Thrombectomy by venous incision was performed with simultaneous iliac vein balloon dilatation and stents implantation. Efficacy and stents patency were assessed. Iliac vein occlusions were confirmed in all 5 patients by angiography after the thrombectomy. Stents implantation were performed after balloon dilatation. Three stents were implanted in 1 case of iliac vein and inferior vena cava (IVC) occlusion, whereas 1 stent was implanted in each of the other 4 cases. RESULTS: Symptoms were significantly relieved after surgery, with no complications. Patients were followed up for 6-24 months, and minor swelling of the affected limb was found in 1 case, with no thrombosis recurrence in all cases and vascular stent patency. CONCLUSIONS: Thrombectomy by venous incision and simultaneous iliac vein stent implantation for the treatment of PCD caused by iliac vein occlusion can quickly relieve symptoms, is easily implemented, is associated with fewer complications, and has good midterm efficacy and a high patency rate, making this technique a good treatment method.

Mondor's disease - a rare cause of chest pain: a case report.

BACKGROUND: Chest pain is one of the common presenting symptoms encountered in an emergency department. Prompt history taking and careful clinical examination do help to differentiate cardiac chest pain from other causes. Mondor's disease is a rare cause of chest pain which is often underdiagnosed due to lack of awareness. Mondor's disease is a condition characterized by thrombophlebitis of the superficial veins of breast and anterior chest wall. The diagnosis is often made clinically. CASE PRESENTATION: Here we report a case of a 37-year-old Sri Lankan Tamil woman who presented with chest pain and was clinically diagnosed as having Mondor's disease after a physical examination, which was confirmed with demonstration of thrombophlebitis by ultrasound scan imaging. Although it is a self-limiting condition, non-steroidal anti-inflammatory drugs are used in the treatment to hasten recovery in addition to giving reassurance. CONCLUSIONS: Mondor's disease is not considered a differential diagnosis for chest pain due to lack of awareness of this medical condition. Creating awareness of this condition via this case would help to cut down unnecessary investigations and valuable time spent in emergency departments, and it helps to identify a serious underlying cause especially carcinoma of the breast at its early stage.

Neonatal Lemierre Syndrome: Youngest Reported Case and Literature Review.

A previously healthy 5-week-old female was admitted for sepsis secondary to methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. After several days of hospitalization, she experienced acute decompensation in mental status despite having received targeted antibiotic therapy. Imaging revealed left peritonsillar/parapharyngeal space abscess, left venous thrombophlebitis of the internal jugular vein, and septic emboli of the lungs and brain consistent with Lemierre syndrome. Bedside needle aspiration of the parapharyngeal abscess confirmed MRSA involvement. Unfortunately, the patient continued to deteriorate over the next several days and life support was withdrawn on hospital day 16. We present the youngest reported case of Lemierre syndrome and review the literature.

[Treatment of a woman with phlegmasia cerulea dolens complicated by massive pulmonary thromboembolism and intestinal haemorrhage]. / Lechenie bol'noi s sinei flegmaziei, oslozhnennoi massivnoi tromboémboliei legochnoi arterii i kishechnym krovotecheniem.

Acute thrombosis of the lower limb deep veins remains one of the most common vascular diseases. It is characterised by formation of thrombotic masses in the system of the deep veins of the lower extremities. A serious complication associated with deep vein thrombosis is pulmonary embolism. In rare cases, under certain conditions a massive and disseminated blockade of the venous outflow with thrombotic masses may lead to ischaemia of the extremity with the formation of superficial and deep necroses and later on to gangrene. One of the main components of management is long-term administration of anticoagulants, which in a series of cases may result in the development of gastrointestinal haemorrhage which in its turn requires discontinuation of anticoagulants. Described herein is a clinical case report concerning treatment of a woman presenting with deep vein thrombosis and the development of phlegmasia cerulean dolens complicated by massive pulmonary artery thromboembolism on the background of intestinal bleeding.

Rare Case of Unilateral Phlegmasia Cerulea Dolens With Bilateral Deep Vein Thrombosis at a Community Military Hospital Emergency Department.

Phlegmasia cerulea dolens (PCD) is a rare entity that refers to a painful, edematous, and cyanotic limb due to a massive deep vein thrombosis (DVT). Due to its rarity, the exact incidence is unknown; however, it is vital that the military health care provider recognize it as the condition can be limb and life threatening. Due to the recent increase in combat-related operations, DVT has had a steady increase in the past 10 years in the military population, and as such has become a condition of special interest and surveillance in the armed forces. PCD is part of a spectrum that consists of distal DVT, more proximal DVT, phlegmasia alba dolens (PAD), and finally PCD with venous gangrene. PAD is an early stage of PCD, in which although there is a massive DVT present, the collateral and superficial circulation are not yet involved; this in turn results in a painful, edematous, white leg. PCD is preceded by PAD in approximately 50% to 60% of the cases. PCD has an amputation rate of up to 50% and a mortality rate of up to 40%. The patient will present with a swollen, cyanotic, painful leg that may or may not show signs of venous gangrene. In PCD, the collateral circulation is not spared and this causes severe congestion and fluid sequestration in the limb leading to venous hypertension. This can lead to circulatory shock and arterial insufficiency as it progresses. We review a case report of a 66-year-old woman that presented to small community army hospital after a 26-hour bus drive with knee pain and leg swelling. The diagnosis of PCD was made after Doppler ultrasonography showed bilateral iliofemoral, common, femoral, and saphenous veins thrombosis. The patient's left lower extremity was discolored, tender, and swollen, although it had not progressed to venous gangrene or dermal necrosis. While the management of PCD is not standardized due to the rarity of the condition, several options are available. These options include anticoagulation, minimally invasive procedures such as catheter-directed thrombolysis, or more invasive procedures such as surgical thrombectomy. In the active duty military population, clot reduction techniques would be preferred to long-standing anticoagulation, as the morbidity is greater with anticoagulation alone as well as the probability of major hemorrhage. Besides pulmonary embolism, which is a complication in up to 30% of the patients with PCD, one must keep in mind the extent and duration of the thrombus when choosing a treatment method, as these factors are directly related to the morbidity associated with post-thrombotic syndrome. Functional impairment after a massive DVT or PCD is an important factor that must be kept in mind for troop readiness.

Clinical Mimics: An Emergency Medicine-Focused Review of Cellulitis Mimics.

BACKGROUND: Cellulitis is a common clinical condition with low rates of morbidity and mortality if treated appropriately. Mimics of cellulitis presenting with erythema, edema, warmth, and pain can be associated with grave morbidity and mortality if misdiagnosed. OBJECTIVE: This review investigates the signs and symptoms of cellulitis, mimics of cellulitis, and an approach to the management of both cellulitis and its mimics. DISCUSSION: The current emergency medicine definition of cellulitis includes erythema, induration, warmth, and swelling. Given the common pathophysiologic pathways, cellulitis mimics often present in an analogous manner. These conditions include septic bursitis, septic joint, deep vein thrombosis, phlegmasia cerulea dolens, necrotizing fasciitis, flexor tenosynovitis, fight bite (closed fist injury), orbital cellulitis, toxic shock syndrome, erysipelas, abscess, felon, paronychia, and gouty arthritis. Many of these diseases have high morbidity and mortality if missed by the emergency physician. Differentiating these mimics from cellulitis can be difficult in the fast-paced emergency setting. A combination of history, physical examination, and focused diagnostic assessment may assist in correctly identifying the underlying etiology. For many of the high mortality cellulitis mimics, surgical intervention is necessary. CONCLUSION: Cellulitis and its mimics present similarly due to the same physiologic responses to skin and soft tissue infections. A combination of history, physical examination, and diagnostic assessment will help the emergency physician differentiate cellulitis from mimics. Surgical intervention is frequently needed for high morbidity and mortality mimics.

[Thrombotic events in patients with hemophilia]. / Tromboticheskie oslozhneniia u bol'nykh gemofiliei.

The paper describes 4 clinical cases of thrombotic events (pulmonary embolism, deep vein thrombophlebitis, acute myocardial infarction, ischemic stroke) that have occurred in patients with hemophilia. It discusses the possible causes of their development and methods for their prevention and treatment. Controlled natural hypocoagulation, in which the dose of an administered deficient factor decreases to such an extent that in order to maintain the safe level of hypocoagulation (plasma factor activity is 15-20%; activated partial thromboplastin time is 1.5-2 times normal values), is proposed as one of the treatment options.

Penile Mondor disease and its effect on erectile function: results of 30 patients.

OBJECTIVE: To investigate the treatment outcomes among patients diagnosed with penile Mondor disease and to evaluate the effect of the disease on erectile function. METHODS: A total of 30 patients diagnosed with penile Mondor disease were enrolled in the study. All patients underwent physical examination and penile Doppler ultrasonography and filled in the International Index of Erectile Function (IIEF-5) questionnaire at regular intervals. Pharmacotherapy was started when penile Mondor disease was diagnosed. After the data were confirmed to be normally distributed using Kolmogorov-Smirnov test, the differences between the 3 IIEF-5 scores were evaluated using repeated measures analysis of variance and post hoc Bonferroni tests. RESULTS: The mean age of the patients was 34.3 years (range, 25-48 years). Ten patients had prolonged sexual intercourse, 4 had recent intestinal infection history, 2 had recent long-haul flights, 1 had sickle cell anemia, and 2 had penile trauma caused by sexual intercourse. Nine patients were considered idiopathic. Mean IIEF-5 scores at the baseline and at 1- and 2-month follow-ups were 20.87, 20.07, and 20.93, respectively. Although no significant difference was found between the baseline and the 2-month follow-up IIEF-5 scores, significant differences between the baseline and the 1-month (P = .004) and the 1- and 2-month follow-up IIEF-5 scores (P = .0001) were detected. CONCLUSION: Penile Mondor disease is a rare complication that can be successfully treated with medical therapy and conservative approach. Our series showed that penile Mondor's disease does not lead to permanent deformation of the penis or erectile dysfunction.

[Condition of the proximal portion of the thrombus in varicophlebitis of the great saphenous vein].

AIM: To assess the state of the proximal portion of a thrombus of the great saphenous vein (GSV) in patients with varicophlebitis by means of duplex scanning of veins. MATERIAL AND METHODS: We examined a total of 40 patients with acute varicophlebitis of the GSV: 11 (27.5%) men and 29 (72.5%) women, the patients' average age amounted to 53.5 years (range 29-78). Duplex scanning (DS) was used to determine: localization and extent of thrombosis, the presence of a free portion, density and configuration of the contour of the proximal portion of the thrombus, proximal level of the inflammatory wall and paravasal fat. RESULTS AND DISCUSSION: Inflammation was located on the crus in 12 (30%) patients, on the femur in 10 (25%), on the crus and femur in 18 (45%) patients. According to the findings of DS, of 28 (70%) patients with femoral inflammation the upper end of the thrombus was located in the lower third of the femur in 9 (22.5%) patients, in the middle third in 11 (27.5%) patients and in 8 (20%) patients in the upper third. In 29 (72.5%) patients the thrombus had no free part, eleven (27.5%) were found to have a floating portion 1.0-10 cm long (averagely 3.58 cm). The incidence of floating thrombi is determined by the diameter of the thrombosed vessel: in femoral localization the floating part was in 9 (22.5%) patients, in crural localization - in 2 (5%). A distinct edge of the proximal contour was present in 30 (75%) patients, diffuse contour in 10 (25%). In 8 (20%) patients the proximal portion of the thrombus by density did not differ from the patients' body. In 3 (7.5%) patients it approximated to density of blood. In the majority of cases (60%) the proximal portion was of cellular character with alternation of portions of various density. Thickness of the altered paravasal fat amounted to 7-20 mm (averagely 8.68 mm). The boarder of the thrombus in 56 (90%) patients located proximal to inflammation of the wall and paravasal fat by 4.0-60.0 cm (averagely 6.0 cm). This demonstrates that clinical symptoms induce phlebitis and paravasal cellulitis. CONCLUSION: Detailed examination of the proximal portion of the thrombus in patients with varicophlebitis of the GSV by means of DS makes it possible to accurately evaluate its condition: assessment of density and configuration provides a more detailed characterisation of the degree of maturity of the proximal portion of the thrombus. Thrombus density comparable with density of liquid blood in combination with its extended free portion may increase the risk of thrombus migration.

[Surgical treatment tactics for acute varicothrombophlebitis atypical forms].

Changes of phlebohemodynamics under control of ultrasonographic investigation were registered in 237 patients, suffering an acute varicothrombophlebitis (AVTH) of superficial veins of lower extremities (LE). In 21 patients atypical forms of AVTH were revealed, including reflux toward a big subcutaneous vein (BSV) of the leg and/or small subcutaneous vein (SSV); reflux toward insufficient indirect veins on hip and shin; reflux toward insufficient direct perforant veins. For atypical forms of AVTH the urgent operations on hip and shin were performed: crossectomy, short or long stripping, phlebectomy and/or scleroobliteration of tributaries; open subfascial resection (mini-Linton); deferred operations: phlebectomy of the BSV/SSV tributaries, open scleroobliteration, subfascial resection (mini-Linton). Systematization of the AVTH forms in accordance to the LE segments have permitted to determine strategy and tactics of the patients treatment, what have important practical significance.

Analysis of 27 cases of large vascular lesions in 161 cases of Behcet's disease: clinical manifestations and treatment outcome.

Very little is known about the features of Behcet's disease (BD) with vascular lesions, especially in Chinese population. This study reports the incidence, pattern, and clinical features of vascular lesions in BD patients in China. A total of 161 patients with BD were screened, and 27 patients with vessel involvement were identified. The clinical and laboratory data of the 27 BD patients with vessel involvements were retrospectively analyzed. Of 161 enrolled patients with BD, 27 had large blood vessel damage (16.77 %), with 24 males and 3 females, indicating clear prevalence in males. The average age of onset was 26.2 years old. Seven patients involved arteries only, 15 had vein damage, and 5 showed damage to both arteries and veins. Although vein lesions were more prevalent, arterial lesions were not rare (44.4 % of the vessel-affected BD patients) and could be life-threatening. All 27 patients received various treatments such as steroids, immunosuppressants, anticoagulants, and surgery, and most responded well as evidenced by resumed blood circulation and complete resolution. In conclusion, this study shows features of vessel that involved BD similar to those reported in literatures. Comprehensive treatments lead to significant improvement in BD patients.