J INVASIVE CARDIOL 2020;32(7):E190.
Key words: intravascular ultrasound, May-Thurner Syndrome, phlegmasia cerulea dolens
A 65-year-old taxi driver presented with acute painful swelling of the left lower limb. On clinical examination, the affected limb was dusky, swollen, and tense (Figure A) with strong peripheral pulses. Bedside Duplex ultrasound demonstrated left iliofemoral venous thrombosis; thus, a clinical diagnosis of phlegmasia cerulea dolens was made. It was complicated with rhabdomyolysis (serum creatine kinase, >30,000 U/L) and acute renal failure (serum creatinine, 300 µmol/L). He underwent urgent venography, which showed extensive thrombus at left common iliac vein with extension to the inferior vena cava (IVC).
Catheter-directed pharmacomechanical thrombectomy was done in order to restore venous return. Subsequent venogram revealed a suspicious narrowing over the left common iliac vein and IVC junction (Figure 1B). Peripheral intravascular ultrasound (IVUS; Vision PV 0.35; Philips Volcano) revealed severe extrinsic compression of the left common iliac vein (Figure 1C) by the right common iliac artery consistent with May-Thurner syndrome. A 14 x 90 mm Vici dedicated nitinol venous stent (Boston Scientific) was deployed from the IVC to the left common femoral vein. Poststenting venogram revealed rapid inflow into the IVC (Figure 1D) and IVUS showed significant common iliac vein lumen gain (Figure 1E). The purple discoloration and pain resolved the next day (Figure 1F) with normalization of renal function in 5 days. He was treated with oral anticoagulation therapy for 6 months and remained symptom free at 18-month follow-up.
Phlegmasia cerulea dolens is a limb- and life-threatening complication of acute massive proximal deep-vein thrombosis, which causes severe lower-limb venous congestion and ischemia. Venography alone may underestimate the extent of common iliac vein compression in May-Thurner syndrome. Peripheral IVUS is mandatory to better assess common iliac vein compression before and after intervention.
From the 1Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong Special Administrative Region, People’s Republic of China; 2Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China; and 3Department of Epidemiology & Preventive Medicine, School of Public Health, Monash University, Melbourne, Australia.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted October 23, 2019.
Address for correspondence: Dr Chi Wai Kin, Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Clinical Science Building, Prince of Wales Hospital, 30-32 NganShing Street, Shatin, NT, Hong Kong SAR, China. Email: email@example.com