key: cord-1022388-dabw8ung authors: Gutierrez, Josue R.; Volteas, Panagiotis; Skripochnik, Edvard; Tassiopoulos, Apostolos K.; Bannazadeh, Mohsen title: A Case of Phlegmasia Cerulea Dolens in a patient with COVID-19, effectively treated with fasciotomy and mechanical thrombectomy date: 2021-10-10 journal: Ann Vasc Surg DOI: 10.1016/j.avsg.2021.07.034 sha: f6ac04112050abae94c9f42423906d3c5dd2502e doc_id: 1022388 cord_uid: dabw8ung Coronavirus disease 2019 (COVID-19) has been widely reported to be associated with increased risk of Venous Thromboembolism (VTE), both deep vein thrombosis (DVT) and pulmonary embolism (PE). A rare and extreme manifestation of DVT is Phlegmasia cerulea dolens (PCD), characterized by poor tissue perfusion due to marked limb swelling which can progress to limb and life-threatening venous gangrene. We report the case of a 53-year-old man with severe SARS-CoV2 pneumonia who developed acute iliofemoral DVT leading to acute limb ischemia due to PCD. The patient underwent successful emergent fasciotomy and mechanical thrombectomy with removal of extensive thrombus burden and restoration of normal venous circulation. Our case highlights the importance of clinical vigilance and early implementation of therapeutic interventions to avoid adverse outcomes in patients who develop SARS-CoV2 induced VTE complications. A 53-year-old male with medical history of hypertension, remote smoking, and diabetes mellitus, 30 presented to the emergency department with fever, weakness, and dry cough for several days. 31 The patient had no personal or familial history of VTE. Laboratory tests showed elevation of 32 several inflammatory markers, such as CRP, ESR, procalcitonin and ferritin, while d-dimer level 33 was mildly elevated of 385 ng/ml (Table 1) . CT scan of the chest showed bilateral patchy 34 ground-glass opacities suggestive of COVID-19 pneumonia, which was confirmed by rapid 35 nasopharyngeal PCR test. Due to signs of hypoxic respiratory failure with additional diabetic 36 ketoacidosis the patient was admitted to the intensive care unit. A central venous catheter was 37 inserted in the right common femoral vein due to hemodynamic instability for vasopressor 38 support and prophylactic low molecular weight heparin at 40 mg twice daily was started. Over the first three hospital days, the patients d-dimer level steadily increased from 385 ng/ml to 40 a peak of 13,709 ng/ml. The patient then complained of severe right leg pain. On physical 41 examination, the right leg was edematous, cyanotic, and cold with tense and exquisitely tender limb ischemia due to PCD, the decision was made to proceed emergently to the operative room. 52 We began with fasciotomy of the anterolateral thigh and four calf compartments followed by Confirmation of the high cumulative 132 incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated 133 analysis Incidence of venous 137 thromboembolism in hospitalized patients with COVID-19 Reduces Mortality in Intubated COVID-19 Patients: A Cohort Study With a Propensity-Matched 144 Front Med (Lausanne) Anticoagulant treatment is associated with 147 decreased mortality in severe coronavirus disease 2019 patients with coagulopathy Association of Treatment Dose Anticoagulation 152 With In-Hospital Survival Among Hospitalized Patients With COVID-19 Pathophysiological Processes Underlying the High Prevalence of Deep 157 Vein Thrombosis in Critically Ill COVID-19 Patients COVID-19 infection with extensive thrombosis: A case of 160 phlegmasia cerulea dolens A 61-Year-Old Man with SARS-CoV-2 Infection 163 and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb 164 Consistent with Phlegmasia Cerulea Dolens Phlegmasia caerulea dolens and venous gangrene Phlegmasia cerulea dolens Trends in management of phlegmasia cerulea 171 dolens. Vasc Endovascular Surg American Venous Forum. Early thrombus removal strategies for acute deep 176 venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the 177 Delayed Yet Successful Mechanical Thrombectomy for Phlegmasia 180 Cerulea Dolens in a Limb with Severe Arterial Disease and May-Thurner Syndrome Surgical Thrombectomy for Phlegmasia Cerulea Dolens. Vasc Specialist Int Successful catheter-directed venous 187 thrombolysis in phlegmasia cerulea dolens Catheter-directed interventions for acute iliocaval deep vein 190 thrombosis Dolens with Percutaneous Mechanical Thrombectomy Surgical Thrombectomy and Simultaneous Stenting for 196 Phlegmasia Cerulea Dolens Caused by Iliac Vein Occlusion Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis