II. Pathophysiology
- Phlegmasia (milk leg)
- Venous outflow obstruction
- Typically left sided due to left common iliac vein course beneath the left common iliac artery
- Progression along a spectrum
- Phlegmasia Alba Dolens
- Phlegmasia Cerulea Dolens
- Venous Gangrene
- Venous outflow obstruction
- Phlegmasia Alba Dolens (Milk Leg Syndrome)
- Pale white, painful, severely edematous extremity (milk leg)
- Proximal deep vein obstruction with patent collateral veins
- Phlegmasia Cerulea Dolens (Copper Leg Syndrome)
- Cyanotic or blue, severely edematous extremity (copper leg) with obstructed collateral veins
- Pain out of proportion to appearance
- Like Alba Dolens, Cerulea Dolens is associated with proximal deep vein obstruction
- However, collateral or superficial veins are also obstructed leading to greater venous obstruction and Cyanosis
- Venous Gangrene
- Thrombosis extends into the capillaries
- Associated with Septic Shock and need for Limb Amputation
-
May-Thurner Syndrome
- Left common iliac vein compressed by right femoral artery and spurring from Vertebrae
- Presents with unilateral left Leg Edema and venous Hypertension
III. Causes
- Ilio-femoral Deep Vein Thrombosis
- Malignancy
- Hypercoagulable State
- Trauma
- Anatomic Compression
- May-Thurner Syndrome (typically left-sided)
- Pregnancy
IV. Differential Diagnosis
V. Imaging
- Extremity CT Venogram (preferred)
- Extremity MR Venogram
VI. Management
- Vascular surgery Consultation in all cases
- Phlegmasia Alba Dolens
- Medical management in most cases (if DVT)
- Phlegmasia Cerulea Dolens
- Emergent surgical thrombectomy or
- Emergent directed Thrombolytics
VII. Prognosis
- Untreated Phlegmasia (esp. cerulea) is associated with very high mortality (20 to 50%)
VIII. References
- Jhun and Herbert in Herbert (2014) EM:Rap 14(5): 8
- Jean-Louis and Sethuraman (2023) Crit Dec Emerg Med 37(7): 4-11