Phlegmasia Cerulea Dolens Secondary to Iliac Vein Compression From Posttransplant Hematoma Despite Anticoagulation

Phlegmasia cerulea dolens is a rare, life- and limb-threatening form of venous thrombosis that is often seen in the setting of hypercoagulable states or mechanical obstruction.

We report the case of a 49-year-old female with a history of multiple thromboembolic events and a methylenetetrahydrofolate reductase mutation who, despite therapeutic anticoagulation, developed phlegmasia cerulea dolens following renal transplantation. Her postoperative course was marked by recurrent hemorrhage with rapidly reaccumulating subincision and perinephric hematomas, requiring 4 exploratory laparotomies for hematoma evacuation and graft evaluation. In addition, the patient underwent urgent endovascular suction thrombectomy for extensive iliofemoral thrombosis caused by extrinsic iliac vein compression.

This case highlights the complex interplay between bleeding and clotting in high-risk transplant recipients and the need for nuanced anticoagulation management. Although phlegmasia cerulea dolens is rare, clinicians must keep a high index of suspicion for the pathology, as early recognition and timely intervention can be both life- and limb-saving.