Phlegmasia alba dolens

Background

• "Milk/White Leg"
• Massive iliofemoral occlusion due to venous thromboembolism
• Spares collateral veins
• Lack of venous congestion

Clinical Spectrum of Venous thromboembolism

• Deep venous thrombosis (uncomplicated)
• Phlegmasia alba dolens
• Phlegmasia cerulea dolens
• Venous gangrene
• Pulmonary embolism
  • Pulmonary embolism in pregnancy
• Isolated distal deep venous thrombosis

Only 40% of ambulatory ED patients with PE have concomitant DVT

Risk Factors

• Age 50-60s
• Malignancy (20-40%)
• Pregnancy
• Inherited thrombophilia
• Trauma/surgery
• 10% idiopathic in patients without risk factors

Clinical Features

• Pain
• Edema
• White appearance/blanching (alba)
• May progress to phlegmasia cerulea dolens
  • Superficial venous system is occluded, resulting in no venous outflow

Differential Diagnosis

• Arterial embolism
• Phlegmasia cerulea dolens
• DVT
• Cellulitis
• Lymphedema
• Venous valvular insufficiency
• Superficial thrombophlebitis

Calf pain

• Achilles tendon rupture
• Calcaneal bursitis
• Cellulitis
• Compartment syndrome
• Deep venous thrombosis (DVT)
• Distal leg fractures
• Gastrocnemius strain
• Ruptured popliteal cyst (Bakers cyst)
• Superficial thrombophlebitis

Evaluation

• Clinical diagnosis
• Duplex US
• Contrast venography
• MRV

Management

• Conservative management
  • Steep limb elevation
  • Fluid resuscitation
  • Heparin: 80-100U/kg followed by infusion of 15-18U/kg/hr
  • Vascular surgery consult
• If conservative therapy fails, can consider:
  • Thrombolysis: Alteplase (1mg/min to total of 50mg) distal to thrombus
  • Interventional radiology consult for emergent catheter-directed thrombolysis
  • Thrombectomy

Disposition

• Admit