Posttraumatic phlegmasia cerulea dolens: an indication for the Greenfield filter

Phlegmasia cerulea dolens (PCD) can be a threat to both life and limb and therefore must receive prompt treatment. In most clinical settings, anticoagulant therapy is standard treatment for PCD. Iliofemoral thrombectomy has been recommended as surgical treatment of massive thrombosis where venous gangrene may occur. In the severely traumatized patient, however, massive venous occlusion presents difficulties in management in a complex clinical setting. We have described a 52-year-old white man who had a posterior fracture dislocation of the right hip, with a pulseless, cyanotic, swollen right leg. A Greenfield filter was placed via the internal jugular vein approach, followed by leg and thigh fasciotomy and iliofemoral thrombectomy. Femoral arteriotomy revealed good inflow, and arterial thrombectomy yielded very little thrombus. He subsequently required an above-knee amputation for venous gangrene. In cases of PCD, iliofemoral thrombectomy should be considered early when the threat of venous gangrene exists. We propose internal jugular vein placement of a Greenfield filter before venous thrombectomy. The Greenfield filter has proven to be a safe and effective prophylaxis for thromboembolism should a clot migrate or detach during thrombectomy. Additionally, placement of the filter in the early post-traumatic period would safeguard against pulmonary emboli during a period in which anti-coagulant therapy would be contraindicated.