Vascular intervention for phlegmasia

This algorithm summarizes our suggested approach to vascular intervention for phlegmasia. Phlegmasia is a severe manifestation of deep venous thrombosis. Early phlegmasia is defined as symptoms and signs of severe venous outflow obstruction (eg, extremity pain, cyanosis, swelling) but arterial doppler signals remain present. With late phlegmasia, arterial doppler signals are absent and neurologic dysfunction may or may not be present; the patient may or may not have evidence of venous gangrene. For additional details, including the evidence supporting the efficacy of these treatments, refer to UpToDate topics on deep venous thrombosis and phlegmasia.

IU: international units; MT: mechanical thrombectomy; PE: pulmonary embolism; UFH: unfractionated heparin.

* Duplex ultrasound demonstrating extensive iliofemoral/caval thrombosis with superficial venous involvement.

¶ Anticoagulate with UFH using an 80 units/kg bolus followed by a continuous infusion of 18 units/kg/hour. Adjust infusion rate to maintain target laboratory values based on institutional protocol. Use an alternative intravenous agent if heparin is contraindicated.

Δ For early phlegmasia, initial vascular intervention may also be appropriate.

◊ MT rapidly removes thrombus using a variety of endovenous devices and is our preferred approach. If MT is not available, pharmacologic thrombolysis can be tried provided symptoms are not progressive. Absolute contraindications to thrombolysis include prior intracranial hemorrhage, known structural cerebral vascular lesion, known malignant intracranial neoplasm, ischemic stroke within 3 months (presuming no stroke within last 3 hours), suspected aortic dissection, active bleeding or bleeding diathesis (excluding menses), significant closed-head trauma or facial trauma within 3 months. Refer to UpToDate topic for complete list including relative contraindications.

§ MT rapidly removes thrombus using a variety of endovenous devices and is our preferred approach. For severe ischemia (eg, venous gangrene), surgical thrombectomy may be more expedient at restoring venous outflow.

¥ Patients with late phlegmasia are at risk for compartment syndrome with reperfusion and may benefit from prophylactic 4 compartment fasciotomy. Patients with confirmed extremity compartment syndrome receive therapeutic 4 compartment fasciotomy.

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Vascular intervention for phlegmasia