Lessons learned from a case of phlegmasia cerulea dolens treated with thrombolysis and iliac vein stenting

Phlegmasia cerulea dolens is a rare manifestation of massive deep vein thrombosis with threat to limb and life. A patient with a background of ovarian malignancy in remission and pelvic radiotherapy presented with left lower limb phlegmasia cerulea dolens as a result of extensive acute left lower limb deep vein thrombosis, extending from the popliteal vein to the inferior vena cava. While initial rapid thrombolysis and left iliac vein stenting were successful, she developed significant hemorrhagic complications from her right radial intra-arterial line with compartment syndrome requiring fasciotomy. She subsequently develops contralateral right lower limb deep vein thrombosis with phlegmasia cerulea dolens as a result of the cessation of anticoagulation and 'jailing' of the contralateral right iliac vein. Repeat thrombolysis with a lower dose of thrombolytics was performed, and contralateral iliac vein stenting in 'kissing' configuration was performed successfully. We discuss several lessons learned from this uncommon but important case.