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Phlegmasia

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Phlegmasia, Milk Leg, Phlegmasia Alba Dolens, Phegmasia Cerulea Dolens, Venous Gangrene, May-Thurner Syndrome

  • Pathophysiology
  1. Phlegmasia (Milk Leg)
    1. Venous outflow obstruction
      1. Typically left sided due to left common iliac vein course beneath the left common iliac artery
    2. Progression along a spectrum
      1. Phlegmasia Alba Dolens
      2. Phlegmasia Cerulea Dolens
      3. Venous Gangrene
  2. Phlegmasia Alba Dolens
    1. Painful white leg
    2. Proximal deep vein obstruction
  3. Phlegmasia Cerulea Dolens
    1. Triad of painful blue leg with edema
      1. Pain out of proportion to appearance
    2. Deep vein and collateral or superficial vein obstruction
      1. Results in venous congestion (edema) which distinguishes it from Phlegmasia Alba Dolens
  4. Venous Gangrene
    1. Thrombosis extends into the capillaries
  5. May-Thurner Syndrome
    1. Left common iliac vein compressed by right femoral artery
    2. Presents with unilateral left Leg Edema and venous Hypertension
    3. Increased risk of left Deep Vein Thrombosis
    4. Diagnosed via Magnetic Resonance Venography (MRV)
  • Causes
  1. Ilio-femoral Deep Vein Thrombosis
    1. Malignancy
    2. Hypercoagulable State
    3. Trauma
  2. Anatomic Compression
    1. May-Thurner Syndrome (typically left-sided)
    2. Pregnancy
  • Differential Diagnosis
  • Imaging
  1. Extremity CT Venogram (preferred)
  2. Extremity MR Venogram
  • Management
  1. Vascular surgery Consultation in all cases
  2. Phlegmasia Alba Dolens
    1. Medical management in most cases (if DVT)
  3. Phlegmasia Cerulea Dolens
    1. Emergent surgical thrombectomy or
    2. Emergent directed Thrombolytics
  • References
  1. Jhun and Herbert in Herbert (2014) EM:Rap 14(5): 8