Phlegmasia alba dolens


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

Clinical Spectrum of Venous thromboembolism

Only 40% of ambulatory ED patients with PE have concomitant DVT[1][2]

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


  • Clinical diagnosis
  • Duplex US
  • Contrast venography
  • MRV


  • 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:
    • Thrombolytic: Alteplase (1mg/min to total of 50mg) distal to thrombus
    • Interventional radiology consult for emergent catheter-directed thrombolysis
    • Thrombectomy


  • Admit


  1. Righini M, Le GG, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008; 371(9621):1343-1352.
  2. Daniel KR, Jackson RE, Kline JA. Utility of the lower extremity venous ultrasound in the diagnosis and exclusion of pulmonary embolism in outpatients. Ann Emerg Med. 2000; 35(6):547-554.
  • Dardik A. (2014, Feb 25). Phlegmasia Alba and Cerulea Dolens. eMedicine. Retrieved 12/21/2014 from
  • Rosen's Emergency Medicine 8th edition. 2013. Chapter: Peripheral Arteriovascular Disease p. 1147.
  • Lip GY, et al. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: Post T, ed. UpToDate. Waltham, Mass.: UpToDate; 2014. Accessed December 21, 2014.