eMedicine Specialties > Vascular Surgery > Medical Topics

Phlegmasia Alba and Cerulea Dolens: Workup

Author: Alan Dardik, MD, PhD, FACS, Associate Professor, Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
Coauthor(s): Dina Rahhal, MD, Postdoctoral Fellow in Transplant Immunology, Institute for Cellular Therapeutics, University of Louisville
Contributor Information and Disclosures

Updated: Sep 10, 2009

Workup

Imaging Studies

  • The diagnoses of phlegmasia alba dolens, phlegmasia cerulea dolens (PCD), and venous gangrene are established mainly via clinical criteria with the assistance of contrast venography and duplex ultrasonography.
    • Although venography is considered the criterion standard for diagnosis, technical difficulties may be encountered in as many as 20-25% of patients. Attempts to perform ascending venography when extensive deep system thrombosis is present may result in nonvisualization of the deep system and a nondiagnostic study result. In these cases, descending venography via the contralateral femoral vein or via the upper extremity veins may provide more information about the iliocaval system and proximal extent of the thrombus.
    • Recent improvements in ultrasonography have made this modality a more reliable and accurate way to assess for proximal deep venous thrombosis (DVT) with less morbidity. In addition, duplex imaging may be repeated as needed to monitor for thrombus propagation. Ultrasonography can also be performed at the bedside in patients who are critically ill or unstable. Ultrasonography is often used to guide the initial venipuncture for diagnostic venography and initiation of thrombolytic therapy.
  • Magnetic resonance venography (MRV) is an evolving modality of diagnostic imaging. Its principal advantage is its ability to easily reveal the proximal and distal extent of thrombus with a single study. Its principal disadvantage is the inability to image acutely ill patients with hemodynamic instability or motion artifacts due to pain.

More on Phlegmasia Alba and Cerulea Dolens

Overview: Phlegmasia Alba and Cerulea Dolens
Workup: Phlegmasia Alba and Cerulea Dolens
Treatment: Phlegmasia Alba and Cerulea Dolens
Follow-up: Phlegmasia Alba and Cerulea Dolens
Multimedia: Phlegmasia Alba and Cerulea Dolens
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Gregoire R. La Phlebite bleue (Phlegmasia Cerulea Dolens). 1938;48:1313-15.

  2. Leriche R, Geisendorf W. Resultats d'une thrombectomie precose avec resction veineuse dans une phlebite grave des deux membres inferieurs. Presse Med. 1939;47:1239.

  3. Hull RD, Raskob GE, Pineo GF. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med. Apr 9 1992;326(15):975-82. [Medline].

  4. Paquet KJ, Popov S, Egli H. [Guidelines and results of consequent fibrinolytic therapy in phlegmasia cerulea dolens]. Dtsch Med Wochenschr. Apr 17 1970;95(16):903-4. [Medline].

  5. Snow V, Qaseem A, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. Feb 6 2007;146(3):204-10. [Medline].

  6. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):454S-545S. [Medline].

  7. Anderson FA Jr, Wheeler HB, Goldberg RJ. A population-based perspective of the hospital incidence and case- fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. May 1991;151(5):933-8. [Medline].

  8. Bird RL, Hamilton G. Treatment options for phlegmasia cerulea dolens. J Vasc Surg. Jun 1995;21(6):998-9. [Medline].

  9. Brockman SK, Vasko JS. Phlegmasia cerulea dolens. Surg Gynecol Obstet. Dec 1965;121(6):1347-56. [Medline].

  10. Colditz GA, Tuden RL, Oster G. Rates of venous thrombosis after general surgery: combined results of randomised clinical trials. Lancet. Jul 19 1986;2(8499):143-6. [Medline].

  11. Comerota AJ, Aldridge SC, Cohen G. A strategy of aggressive regional therapy for acute iliofemoral venous thrombosis with contemporary venous thrombectomy or catheter-directed thrombolysis. J Vasc Surg. Aug 1994;20(2):244-54. [Medline].

  12. Haimovici H. The ischemic forms of venous thrombosis. 1. Phlegmasia cerulea dolens. 2. Venous gangrene. J Cardiovasc Surg (Torino). Sep 5-18 1965;Suppl:164-73. [Medline].

  13. Hildanus F. De Gangraena et Sphaelo Cologne. In: Gangrene of the extremities of venous origin. Review of literature. 1950:225-240.

  14. Huisman MV, Buller HR, ten Cate JW. Serial impedance plethysmography for suspected deep venous thrombosis in outpatients. The Amsterdam General Practitioner Study. N Engl J Med. Mar 27 1986;314(13):823-8. [Medline].

  15. Hull RD, Hirsh J, Carter CJ. Diagnostic efficacy of impedance plethysmography for clinically suspected deep-vein thrombosis. A randomized trial. Ann Intern Med. Jan 1985;102(1):21-8. [Medline].

  16. Langeron P, Gillot C. [Phlegmasia caerulea dolens . Acute venous stasis and ischemic phlebothrombosis]. J Mal Vasc. 1992;17(2):116-27. [Medline].

  17. Lansing AM, Davis WM. Five-year follow-up study of iliofemoral venous thrombectomy. Ann Surg. Oct 1968;168(4):620-8. [Medline].

  18. Lin SC, Mousa A, Bernheim J. Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach-a case report. Vasc Endovascular Surg. 2005;39:273-279.

  19. Mahomed A, Williams D. Phlegmasia caerulea dolens and venous gangrene. Br J Surg. Aug 1996;83(8):1160-1. [Medline].

  20. Mahorner H. Diagnosis and treatment of phlegmasia alba dolens and phlegmasia cerulea dolens. Am Surg. Mar 1968;34(3):210-2. [Medline].

  21. Nachbur BH, Ris HB. Thrombectomy in acute deep vein thrombosis: long term follow-up. In: Bergan J, James ST, ed. Yao Venous Disorders. Philadelphia, Pa:. WB Saunders;1991:181-197.

  22. Patel NH, Plorde JJ, Meissner M. Catheter-directed thrombolysis in the treatment of phlegmasia cerulea dolens. Ann Vasc Surg. Sep 1998;12(5):471-5. [Medline].

  23. Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg. Jan 1996;83(1):19-23. [Medline].

  24. Prandoni P, Lensing AW, Buller HR. Comparison of subcutaneous low-molecular-weight heparin with intravenous standard heparin in proximal deep-vein thrombosis. Lancet. Feb 22 1992;339(8791):441-5. [Medline].

  25. Reber PU, Patel AG, Genyk I. Crossover saphenous vein bypass (Palma) in phlegmasia caerulea dolens caused by total iliac outflow obstruction. J Am Coll Surg. Nov 1999;189(5):527-9. [Medline].

  26. Simonneau G, Sors H, Charbonnier B, Page Y, Laaban JP, Azarian R, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. The THESEE Study Group. Tinzaparine ou Heparine Standard: Evaluations dans l'Embolie Pulmonaire. N Engl J Med. Sep 4 1997;337(10):663-9. [Medline].

  27. Sumner D. Essential Hemodynamics Principles 2000. In: Vascular Surgery Rutherford. 5th ed. Philadelphia, Pa:. WB Saunders;2000:73-120.

  28. The Columbus Investigators. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism. The Columbus Investigators. N Engl J Med. Sep 4 1997;337(10):657-62. [Medline].

  29. Weaver FA, Meacham PW, Adkins RB. Phlegmasia cerulea dolens: therapeutic considerations. South Med J. Mar 1988;81(3):306-12. [Medline].

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines

Snow V, Qaseem A, Barry P, Hornbake ER, Rodnick JE, Tobolic T, Ireland B, Segal JB, Bass EB, Weiss KB, Green L, Owens DK, American College of Physicians, American Academy of Family Physicians Panel on Deep Venous. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2007 Feb 6;146(3):204-10. 5

Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):454S-545S. 6

[ CLOSE WINDOW ]

Keywords

phlegmasia alba dolens, phlegmasia cerulea dolens, PCD, venous gangrene, surgical thrombectomy, thrombolysis, pulmonary embolism, PE, deep venous thrombosis, DVT, thromboembolism, venous thromboembolism, thrombosis, hypercoagulable syndrome, gastroenteritis, mitral valve stenosis, heart failure, vena caval filter insertion, May-Thurner syndrome, massive thrombosis, ulcerative colitis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Alan Dardik, MD, PhD, FACS, Associate Professor, Department of Surgery, Section of Vascular Surgery, Yale University School of Medicine
Alan Dardik, MD, PhD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Cell Biology, Association for Academic Surgery, Association of VA Surgeons, Eastern Vascular Society, Peripheral Vascular Surgery Society, Phi Beta Kappa, Society for Clinical Vascular Surgery, Society for Vascular Medicine and Biology, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Dina Rahhal, MD, Postdoctoral Fellow in Transplant Immunology, Institute for Cellular Therapeutics, University of Louisville
Disclosure: Nothing to disclose.

Medical Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.