Successful treatment of posttraumatic phlegmasia cerulea dolens by reconstructing the external iliac vein: a case report

Abstract

Introduction: Phlegmasia cerulea dolens is a rare condition caused by complete venous occlusion leading to impaired arterial flow. To prevent progression to limb gangrene, prompt diagnosis and treatment initiation are paramount. Here we report a rare case of posttraumatic phlegmasia cerulea dolens after ligation of the iliac vein to save the patient's life, with successful treatment by reconstructing the external iliac vein. This is the first report of posttraumatic phlegmasia cerulea dolens induced by iliac vein ligation.

Case presentation: A 49-year-old Chinese man was admitted to a local hospital for severe knife trauma with massive intraperitoneal bleeding. During exploratory laparotomy, he was diagnosed with traumatic rupture of his left external iliac vein without injury to the iliac artery. The proximal and distal parts of his injured external iliac vein were ligated to control the bleeding and rescue him, but his left leg quickly became severe swollen, cyanotic and pulseless. He was diagnosed with posttraumatic phlegmasia cerulea dolens after being transferred to our university hospital. After a retrievable filter was placed in his inferior vena cava via his right femoral vein, he underwent reopening of his abdomen followed by successful surgical reconstruction of his left iliac vein. He was treated with anticoagulation therapy postoperatively and his signs and symptoms improved markedly. He was discharged in a stable condition, with nearly full resolution of symptoms, 35 days after the operation.

Conclusions: Our case demonstrates that ligation of an injured iliac vein may induce phlegmasia cerulea dolens in a posttraumatic scenario; prompt reconstruction of the iliac vein to restore the venous drainage is an effective treatment for phlegmasia cerulea dolens with impending gangrene.

Figure 1

The appearance of the left leg. a. Initial appearance of the left leg, showing significant swelling and cyanosis. b. Appearance of the left leg 35 days after operation, at the time of the patient’s discharge.

Figure 2

An OptEase® retrievable vena cava filter was placed in the inferior vena cava via the right femoral vein under digital subtraction angiography, and a venogram showed total occlusion of the left iliac vein.

Figure 3

The left iliac vein, although narrower after repair, was patent.

Figure 4

Final venogram showing a patent left external iliac vein with a small amount of residual thrombus.