Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 20-year-old Caucasian male (CM) is admitted to the hospital with a right lower extremity (RLE) pain for 1 week. The pain started when he was jumping on a trampoline and he thinks that he might have twisted his ankle. Two days later he noted swelling of his right leg, which is getting progressively worse.
He was admitted to a hospital and a Duplex of RLE showed a large DVT extending from the ankle to the femoral vein in the groin area. Heparin IV was started, overlapped with Coumadin 2 days later.
Past medical history (PMH)
Family medical history (FMH)
Father with protein S deficiency who is on Coumadin. Every time his father stops Coumadin, he gets a "mini-stroke", as per the patient's description.
WD/WN in NAD.
RLE: massive swelling from the right ankle to the upper thigh, with palpable pulses, warm to touch, non-pitting edema.
The rest of the physical examination is unremarkable.
What is the most likely diagnosis?
DVT due to trauma, possible hypercoagualable state due to the positive FMH.
Five days later, the RLE pain is the same or worse, and the circumference of the leg increased despite the anticoagulation treatment.
The patient complained of some fleeting chest pain, and a CT of the chest was ordered to rule out a PE. CT scan was negative.
What do you think is going on?
The patient is at risk for developing phlegmasia cerulea dolens - massive proximal lower extremity thrombosis associated with severe symptomatic swelling or limb-threatening ischemia. Luckily, at the moment his pulses were palpable but the fact that the swelling and pain increased despite 5 days of anticoagualtion is worrisome.
What would you do?
The patient was transferred to a tertiary care center where the vascular medicine consultant recommended a vascular surgery consult. The vascular surgeon ordered systemic thrombolysis with tPA IV at the dose of 0.05 mg/kg/h over 24 hours.
What happened next?
After the thrombolysis, the RLE swelling decreased in size, pain was controlled and the patient was discharged home.
Massive Lower Extremity DVT Treated with Thrombolysis.
What did we learn from this case?
Consider thrombolysis for patients with massive LE DVT that can be limb-threatening. The thrombolytic agent can be deliver systemically (IV) or through a catheter, directly into the clot. The catheter-directed thrombolysis is the preferred treatment method.
The indications for systemic thrombolytic therapy are a massive iliofemoral DVT (especially in the case of phlegmasia cerulea dolens) and PE with hemodynamic instability.
Thrombolytic agents appear to be beneficial if given up to two weeks after DVT is diagnosed.
Bleeding is the main complication of thrombolytic therapy. When given systemically, the streptokinase leads to 3 times more bleeding episodes than the standard anticoagulation with heparin. In addition, many patients with DVT present after surgery, and the thrombolysis is contraindicated in the settings of recent surgery.
Oral rivaroxaban is non-inferior to standard therapy for symptomatic pulmonary embolism (PE) and DVT (NEJM, 2012).
Thrombolytic therapy in venous thromboembolism - UpToDate (pais subscription required)
Thrombolytic Therapy - eMedicine
Catheter-Directed Thrombolysis for the Treatment of Symptomatic DVT - Circulation
Venous Thromboembolism Therapy. Cleveland Clinic.
Phlegmasia Cerulea Dolens. NEJM, Volume 356:e3, January 18, 2007, Number 3.
Image source: Saphenous vein, Gray's Anatomy, 1918 (public domain).