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Vein or artery?

01 February 2004

Mrs T, a housewife in her thirties, was in the first trimester of pregnancy. She’d had trouble with lower back pain, which suddenly intensified one Sunday morning. She attended her local out-of-hours co-operative and coincidentally saw her own GP, Dr F.

Dr F suspected her symptoms were due to urinary tract infection or mechanical back pain, finding nil of note on examination.
Urinalysis was unremarkable. Dr F prescribed cephalexin and simple analgesia.

A few hours later Mrs T was worse and her husband arranged a home visit via the co-operative. Dr P attended, noting swelling and cyanosis of the whole right leg and severe lower-back pain with localised lumbar tenderness. Dr P treated Mrs T with pentazocine.

He advised Mrs T to contact him if things hadn’t improved within two hours. Mrs T’s condition worsened and she was admitted to her local hospital, under the acute surgical team.

Mr L, the surgical registrar on call, noted the history of a blue, painful right leg with back pain, coming on over a few hours. He noted that the leg was oedematous, cold to touch and that there were no palpable pulses. Doppler ultrasound revealed faint arterial signals in the right leg.

Mr L diagnosed acute ischaemia of the right lower limb and took Mrs T to theatre, exploring the right femoral artery and attempting embolectomy with a Fogarty catheter. This was unsuccessful and Mr L had difficulties in closing the arteriotomy, calling for assistance from Miss R, a vascular-surgical consultant. Miss R found a markedly dilated common femoral vein and damage to the femoral artery at the arteriotomy site, requiring grafting.

Mrs T’s leg didn’t improve. She underwent fasciotomy, with little effect, eventually needing a right above-knee amputation due to gangrene of the leg. She suffered long-term problems with infection, which delayed healing of the stump.

Mrs T started a legal claim alleging incomplete examination and failure to refer to hospital by Drs F and P. The hospital was alleged to have been negligent in wrongly diagnosing acute lower limb ischaemia, subjecting Mrs T to unnecessary surgery and failing to administer correct therapy.

Expert advice

We sought GP and vascular surgical advice. The correct diagnosis was felt to be an acute ilio-femoral venous thrombosis resulting in phlegmasia cerulea dolens (venous gangrene). GP advice was supportive of Dr F’s approach, particularly as the history given by Mrs T, once in hospital, revealed that her leg was not swollen when she saw Dr F.

Some experts felt Dr P should have arranged earlier admission to hospital, but the major criticisms were reserved for Mr L.
The presence of marked oedema was felt to be atypical of acute embolic ischaemia, and should have prompted a search for an alternative diagnosis.

The preferred course on admission was to perform duplex-ultrasound scanning of the leg, looking for evidence of venous thrombosis, or if this was unavailable, expectant treatment for extensive venous thrombosis (heparinisation and elevation of the limb).

The experts thought there was a good chance that Mrs T’s leg would have been saved if this course had been followed. The attempted arterial embolectomy may have compromised the blood supply to Mrs T’s leg, making amputation more likely, and was certainly unhelpful. We defended Drs F and P and liability was accepted by the hospital employing Mr L.

Learning points

Massive venous thrombosis can cause ischaemia of a limb (particularly the lower limb) due to severe interstitial oedema restricting arteriolar blood supply.

Where significant oedema occurs in an acutely painful cold and blue limb, massive venous thrombosis is likely and must be positively excluded before considering other diagnoses.

An informative review article advising on up-to-date strategies for diagnosis and management of this condition and its close relative, phlegmasia alba dolens (where the limb is acutely swollen, painful and white) can be found at emedicine.medscape.com/article/461809-overview.

There is debate about the optimal therapy for massive venous thrombosis. A recent article by Arcasoy and Vachani discusses the evidence basis for the available treatments and considers the evidence for local and systemic thrombolytic therapy, and useful future research questions.

See Arcasoy SM and Vachani A, ‘Local and Systemic Therapy for Acute Venous Thromboembolism.’ Clin Chest Med 24(1):73–91(2003).