key: cord-0828202-3gqzeakb
authors: Chun, Tristen T.; Jimenez, Juan Carlos; Pantoja, Joe L.; Moriarty, John M.; Freeman, Shanna
title: Phlegmasia Cerulea Dolens Associated with Acute COVID-19 Pneumonia Despite Supratherapeutic Warfarin Anticoagulation
date: 2020-10-19
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2020.10.002
sha: 709cbef899046b0731ddd0a16e71dbabb9643b47
doc_id: 828202
cord_uid: 3gqzeakb

Patients with acute Coronavirus-19 (COVID-19) respiratory infections are associated with concomitant thromboembolic complications and a hypercoagulable state. Although these mechanisms are not completely understood, unique alterations in serum markers for hemostasis and thrombosis have been detected. A high index of suspicion is required by vascular surgeons in patients presenting with this novel virus. We present the case of a 51 year old male with acute COVID-19 pneumonia who developed Phlegmasia Cerulea Dolens despite chronic warfarin therapy and a supratherapeutic International Normalized Ratio (INR).

A 51-year-old man presented to an outside hospital with a two-day history of cough, fever and 2 shortness of breath, and was admitted with a diagnosis of acute COVID-19 pneumonia. He 3 progressed to acute hypoxic respiratory failure (80% oxygen saturation on 60% Bilevel Positive 4

Airway Pressure [BIPAP]) but refused intubation. His past medical history included congenital 5 tricuspid atresia and pulmonic stenosis repaired with a Fontan procedure as a child. The patient 6 was on long-term warfarin use secondary to recurrent paroxysmal atrial flutter. He had no prior 7 history of deep venous thrombosis (DVT) or hypercoagulable condition. He was also noted to 8 have moderate, constant pain mostly in the foot but up to the midshin, thigh and calf edema, 9 motor weakness and discoloration in his left lower extremity. All leg and thigh muscle 10 compartments were soft on physical examination (FIGURE 1). Upon presentation to an outside 11 hospital, his international normalized ratio (INR) was found to be supratherapeutic (7.5), and he 12 The patient's anticoagulation was maintained on a heparin drip protocol with a goal PTT level 5 between 86 and 110. On hospital day 1 following admission to our tertiary care center, the 6 patient underwent lower extremity venography, placement of a retrievable filter and mechanical 7 thrombectomy using ClotTriever® (Inari Medical) with successful restoration of patency in the 8 left popliteal, femoral and iliac veins (FIGURE 2). The filter was subsequently removed 5 days 9 after its placement. The patient was continued on anticoagulation with therapeutic dosing of 10

Lovenox. His D-Dimer level peaked at 21,450 ng/ml just prior to his transfer to our tertiary care 11 center (5 days after initial presentation). Further hypercoagulable studies obtained on hospital 12 day 1 following admission to our tertiary care center revealed that Cardiolipin Immunoglobulin 13 He was discharged to home 9 days later, back on warfarin with INR goal between 2 and 3 21 22

First described in the 16 th century, PCD is a life and limb threatening condition characterized by 1 irreversible tissue ischemia. Its etiology is extensive central and peripheral DVT with resultant 2 severe venous outflow obstruction. Early signs include pain and edema which can progress to 3 cyanosis, bullae, sensory and motor impairment and gangrene. (FIGURES 3 and 4) Arterial 4 occlusion and compartment syndrome may or may not be present. 1 Concomitant 5 hypercoagulable conditions are frequently present and can include: malignancy, inferior vena 6 cava filters, and inherited thrombophilic conditions. 2 Immediate anticoagulation and rapid 7 restoration of venous outflow in the affected extremity is usually required for limb salvage. 

Phlegmasia cerulea dolens with compartment syndrome

Trends in management of phlegmasia cerulea dolens

Coagulation abnormalities and thrombosis in patients with COVID-19