Unusual problems of venous thrombosis

Although venous thrombosis (thrombophlebitis) is well known, there are uncommon manifestations which are seen infrequently, discussed rarely, and documented poorly. Experiences with 38 patients in seven categories are discussed in terms of our results and the pertinent reports of others. Pulmonary necrosis after embolic pulmonary infarction (six patients) may require tube thoracotomy and/or lung resection and contraindicate further heparin therapy. Iliac and/or femoral vein thrombosis occasionally fails to recanalize. Long-standing occlusion (18 patients) may be benefited by a cross-over saphenous vein graft. Left iliac venous occlusion secondary to pressure from the crossing right iliac artery (four patients) may indicate repair or bypass. Budd-Chiari syndrome (thrombosis of the hepatic venous outflow) was, in a single patient, carried past a critical period by a long Dacron tube shunt graft from the umbilical vein to the azygos vein. Subclavian and axillary venous thrombosis due to thoracic outlet pressure syndrome (three patients) often responds to heparin but may require thrombectomy; later resection of the first rib is indicated. Phlegmasia cerulea dolens (blue phlebitis) with tissue gangrene (three patients) requires immediate venous thrombectomy and subsequent heparinization. The occluded inferior vena cava (three patients) remains a challenging unsolved problem.