Phlegmasia Cerulea Dolens

History

An elderly gentleman with known lung cancer who was on warfarin presented with rapid onset of a painful blue leg. He had a past history of peripheral arterial disease and distal pulses could not be felt on either side.

Ultrasound Findings

Grey scale imaging revealed an echogenic mass filling the right common  femoral vein (which prevented compression of the vein). No flow is seen on colour imaging. The mass was seen to extend proximally into the external iliac vein with absence of the normal color Doppler flow. The IVC contained an echogenic mass which extended proximally to just below the liver.

Examination of the left sided venous system also revealed echogenic clot in the external iliac to femoral veins (not shown).

The veins distal to the femoral veins were not examined.

Conclusion

Extensive venous thrombosis extending from the IVC bilaterally into iliac and femoral veins.

Learning point

DVT should be followed proximally to determine if they extend to the IVC. Repeated compression of a DVT should not be performed due to risk of embolisation, although it is controversial if it should be performed once to ensure the echogenic material is not spontaneous echo contrast due to low flow.

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