Clinical Challenges in Vascular Surgery: Phlegmasia in Pregnancy

A 25-year-old pregnant woman presents with a 1-day history of progressive pain and swelling. The foot is cold, pulseless and neurologic function is deteriorating by the hour. Imaging shows a massive iliofemoral DVT. Now both the limb and the pregnancy are threatened. Do you anticoagulate, thrombolyse or operate? Join us as we break down the management and decision making behind this rare but devastating case.
Hosts:
· Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center
· Paul Haser -Division Chief, Vascular Surgery, Brookdale Hospital Medical Center
· Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center
· Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center
Learning objectives:
- Recognize the clinical presentation and pathophysiology of phlegmasia cerulea dolens
- Describe how pregnancy affects decision making in patients with phlegmasia and venous thromboembolic disease
- Discuss the goals of treatment for patients with DVT’s and identify when operative intervention is indicated
- Describe the sequelae of DVT’s and how this relates to post thrombotic syndrome
- Review the indications, risks, and limitations of anticoagulation, catheter-directed thrombolysis, thrombectomy, and fasciotomy in the management of DVT and phlegmasia.
- Explain the role of IVUS in managing venous thromboembolic disease and May Thurner syndrome
References:
- Vedantham, S., Goldhaber, S. Z., Julian, J. A., Kahn, S. R., Jaff, M. R., Cohen, D. J., Magnuson, E., Razavi, M. K., Comerota, A. J., Gornik, H. L., Murphy, T. P., Lewis, L., Duncan, J. R., Nieters, P., Derfler, M. C., Filion, M., Gu, C.-S., Kee, S., Schneider, J., … Kearon, C. (2017). Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. New England Journal of Medicine, 377(23), 2240–2252. doi.org/10.1056/NEJMoa1615066
- Gomes, M. S., Guimarães, M., & Montenegro, N. (2019). Thrombolysis in pregnancy: A literature review. Journal of Maternal-Fetal & Neonatal Medicine, 32(14), 2418–2428. doi.org/10.1080/14767058.2018.1438402
- Mangla, A., & Hamad, H. (2023). May-Thurner syndrome. In StatPearls. StatPearls Publishing. ncbi.nlm.nih.gov/books/NBK554377
- Bates, S. M., Rajasekhar, A., Middeldorp, S., McLintock, C., Rodger, M. A., James, A. H., et al. (2018). American Society of Hematology 2018 guidelines for management of venous thromboembolism: Venous thromboembolism in the context of pregnancy. Blood Advances, 2(22), 3317–3359. doi.org/10.1182/bloodadvances.2018024802
- Kahn, S. R., Comerota, A. J., Cushman, M., Evans, N. S., Ginsberg, J. S., Goldenberg, N. A., et al. (2014). The postthrombotic syndrome: Evidence-based prevention, diagnosis, and treatment strategies. Circulation, 130(18), 1636–1661. doi.org/10.1161/CIR.0000000000000130 pubmed.ncbi.nlm.nih.gov/25246013
Sponsor URL: goremedical.com
If you liked this episode, check out our recent episodes here: behindtheknife.org/listen
Behind the Knife Premium: behindtheknife.org/premium
Oral Board Review:behindtheknife.org/oral-board
Oral Board Simulator: behindtheknife.org/oral-board/simulator
General Surgery Oral Board Review Course: behindtheknife.org/premium/general-surgery-ora…
Trauma Surgery Video Atlas: behindtheknife.org/premium/trauma-surgery-vide…
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: behindtheknife.org/premium/dominate-surgery-a-…
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: behindtheknife.org/premium/dominate-surgery-fo…
Vascular Surgery Oral Board Review Course: behindtheknife.org/premium/vascular-surgery-or…
Colorectal Surgery Oral Board Review Course: behindtheknife.org/premium/colorectal-surgery-…
Surgical Oncology Oral Board Review Course: behindtheknife.org/premium/surgical-oncology-o…
Cardiothoracic Oral Board Review Course: behindtheknife.org/premium/cardiothoracic-surg…
Download our App:
Apple App Store: apps.apple.com/us/app/behind-the-knife/id16724…
Android/Google Play: play.google.com/store/apps/details?id=com.btk.…