Surgical Treatment for Phlegmasia Cerúlea Dolens: About a Case in the Immediate Puerperium

20-year-old woman, with no previous underlying pathologies, with a history of vaginal delivery 10 days earlier, pain in the left lower limb and edema of approximately 5 days of evolution with changes in skin color. Physical examination: left lower limb with increased volume along its entire length accompanied by cyanosis and decreased temperature from the distal third of the thigh to the dorsal and plantar region of the foot, with tension of muscle mass from the proximal third of the thigh to the distal, femoral, popliteal, pedial and posterior tibial pulses absent. Venous Doppler: iliacofemoral DVT (fig. 1).



Results:

Anticoagulant therapy was started with Enoxaparin at therapeutic doses and the patient was immediately taken to the operating room. Retrograde thrombectomy of the iliac vein was performed with Fogarty 5 Fr catheter, obtaining abundant recent clots and, in addition, some organized clots. Adequate reflux was observed. Finally, fasciotomy at thigh and leg level was performed. Satisfactory evolution with total reduction of edema and cyanosis, absence of pain without limitation of mobility, with palpable pulses. Discharge on the 5th postoperative day with daily dressings, elastic bandage and Acenocoumarol 4 mg/day. Complete wound healing at 30 days (fig. 2).



Conclusions:

Phlegmasia cerulea dolens is a limb-threatening entity, therefore, therapy must be aggressive and rapid, with the aim of preserving the limb, preventing the propagation and formation of the clot and preserving venous patency. On the other hand, recovery with pharmacotherapy alone is infrequent, usually requiring the use of thrombolysis or surgical techniques. Surgical thrombectomy is still considered the gold standard today, as it offers faster and safer recanalization with recanalization rates of almost 100%. In this case, a surgical approach was established with a satisfactory evolution, so we conclude that it is a valuable tool that should not be abandoned and should be part of a vascular surgeon's training.