Phlegmasia cerulea dolens with venous-induced arterial inflow compromise successfully treated by single-session pharmacomechanical thrombectomy: A case report

Phlegmasia cerulea dolens (PCD) is a rare but catastrophic manifestation of venous thromboembolism characterized by near-complete iliofemoral venous occlusion, severe venous hypertension, and secondary arterial inflow compromise. Delayed intervention is associated with venous gangrene, limb loss, and high mortality rates. A 76-year-old male with active rectal malignancy on chemotherapy presented with acute left lower limb pain, swelling, coldness, and cyanosis. CT run-off demonstrated extensive iliofemoral deep venous thrombosis extending from the inferior vena cava (IVC) bifurcation to the infrapopliteal veins, accompanied by loss of distal arterial opacification without intrinsic arterial occlusion-findings diagnostic of advanced PCD with venous-induced arterial inflow collapse. The patient underwent urgent single-session pharmacomechanical thrombectomy using large-bore aspiration with adjunctive low-dose intraprocedural tissue plasminogen activator (tPA) boluses, without catheter-directed thrombolytic infusion. Rapid venous decompression resulted in immediate clinical and hemodynamic improvement, restoration of arterial Doppler signals, and limb salvage. Post-procedural follow-up confirmed sustained limb viability and complete clinical resolution of venous congestion without evidence of recurrent thrombosis. Single-session pharmacomechanical thrombectomy with limited intraprocedural thrombolytic dosing is an effective, limb-saving strategy for advanced PCD, particularly in high-risk oncologic patients.