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• W4387248345 abstract "SESSION TITLE: Vascular Complications in the ICU SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Phlegmasia cerulea dolens (PCD) is an uncommon occurrence in medicine, where acute massive venous thrombosis leads to obstruction of venous drainage of an extremity. This clinical manifestation can impair arterial supply such that circulatory collapse and shock can ensue, carrying a very high morbidity where delay in treatment can lead to loss of limb and death (1). Early diagnosis and appropriate therapeutic intervention are crucial to reduce overall mortality. The mainstay of treatment includes reducing propagation of clotting, avoiding states of shock, preventing progression to gangrene and treating the underlying condition. Here we present a case of a trauma patient who developed refractory obstructive shock secondary to phlegmasia cerulea dolens after having an IVC filter placed prophylactically. CASE PRESENTATION: A 52-year-old male presented to the ED after sustaining a gunshot wound to the right lateral chest. He was found to have grade 4 severe liver laceration and underwent right hepatic artery embolization and massive transfusion protocol for hemorrhagic shock. The patient subsequently became profoundly hypotensive with no evidence of bleeding and stable hemoglobin; he was taken emergently for exploratory laparotomy for concerns of devastating bowel injury. A prophylactic IVC filter was placed the following day. Days later, the patient complained of left lower extremity pain with inability to move his toes. Venous ultrasound demonstrated extensive bilateral deep venous thrombosis (DVT) extending from popliteal to femoral veins. Patient developed obstructive shock requiring multiple vasopressors, suspected secondary to PCD. The IVC filter showed complete thrombosis with collateral vessel formation. The patient underwent IVC thrombectomy with Angiojet, bilateral lower extremity mechanical aspiration thrombectomy, and thrombolysis. Development of compartment syndrome led to bilateral fasciotomies. After subsequent below the knee amputation of the left leg for lower extremity gangrene, he was discharged to a rehab facility. DISCUSSION: IVC filters are placed prophylactically at times if there is high risk of clotting and a contraindication to anticoagulation, however, studies have not shown any benefit. In high-risk patients with proximal DVT, the benefit of IVC filter placement was counterbalanced by an excess of recurrent DVT with no mortality benefit (2). When PCD occurs, it becomes a risk of life or limb; where despite aggressive multidisciplinary interventions with resuscitation, anticoagulation, and limb and life salvaging strategies, the overall amputation rates remain high in those who survive. CONCLUSIONS: The progression of DVT to phlegmasia after venal caval interruption with a filter is rare but has been observed in the literature. In PCD, the progression to venous gangrene increases mortality, highlighting the importance of early intervention with anticoagulation, thrombolysis, or thrombectomy (3). REFERENCE #1: Kou CJ, Batzlaff C, Bezzant ML, Sjulin T. Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis. Cureus. 2020 Jun 12;12(6):e8587. doi: 10.7759/cureus.8587. PMID: 32670722; PMCID: PMC7358928. REFERENCE #2: Muneeb A, Dhamoon AS. Inferior Vena Cava Filter. 2022 Aug 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31751090. REFERENCE #3: Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg. 1996 Jan;83(1):19-23. doi: 10.1002/bjs.1800830106. PMID: 8653352. DISCLOSURES: No relevant relationships by Jose Acosta-Rullan No relevant relationships by Raiko Diaz No relevant relationships by Daniel Heller No relevant relationships by Ana Martinez Nunez No relevant relationships by Rafael Miret No relevant relationships by Shany Quevedo" @default.
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• W4387248345 date "2023-10-01" @default.
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• W4387248345 title "CAUGHT IN A FILTER: WHEN AN IVC FILTER LEADS TO OBSTRUCTIVE SHOCK AND PHLEGMASIA CERULEA DOLENS" @default.
• W4387248345 doi "https://doi.org/10.1016/j.chest.2023.07.1917" @default.
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