A 75-year-old male presented at our emergency department with painful swelling of his left leg for 12 hours without prior trauma history (). He also complained of numbness and weakness of the left lower leg and foot. His medical history was notable for hypertension and hyperlipidemia. On physical examination, the entire leg showed purplish discolorization and left femoral and dorsalis pedis artery pulses were detectable by hand-held Doppler. Duplex ultrasound (DUS) revealed left ilio-femoro-popliteal DVT (). Intravenous heparin was immediately administered and an emergent venous thrombectomy was performed under local anesthesia (), which provided pain relief. The next day, the left leg color was normalized () and motor and sensory defects were fully recovered. Anticoagulation therapy was prescribed for 6 months and follow-up computed tomography (CT) at 6 months revealed no residual thrombus ().
A 49-year-old Chinese man sustained severe knife trauma and was referred to a local hospital. An exploratory laparotomy showed traumatic rupture of his left external iliac vein with massive intraperitoneal bleeding, but his iliac artery was intact. To rescue him, the proximal and distal parts of his injured external iliac vein were ligated (there was no vascular surgeon in the local hospital); however, his left leg quickly became severely swollen, cyanotic and pulseless. Two hours after the first operation, he was transferred to the emergency department of our university hospital with endotracheal tube intubation. On physical examination, he was tachycardic (142 beats per minute), hypotensive (86/50mmHg). His left lower extremity was markedly edematous, cyanotic, mottled (Figure \na) and had no palpable pulse, but his right lower extremity was normal. He was diagnosed with posttraumatic PCD. Considering the high risk of pulmonary embolism during the next surgical procedure, an OptEase® retrievable vena cava filter (Cordis Corp., New Brunswick, NJ, USA) was placed in his inferior vena cava via his right femoral vein under digital subtraction angiography (Figure \n). His abdomen was immediately reopened while his left leg was also prepared for treatment.During the second emergent laparotomy, there was less blood in his pelvic cavity. No active bleeding was identified. His left iliac vein and artery were exposed and his entire iliac artery appeared normal and without rupture. His external iliac vein was ligated but not transected, connected only by the posterior wall, and the caudal part of his iliac vein was significantly dilated. By replacing the vascular clamp in the proximal and distal parts of the rupture, the ligations on both sides of the venous rupture were resolved. A wedge-shaped rupture was revealed, approximately 4cm in length, on the anterolateral side of his left external iliac vein. The edges of the venous rupture were smooth as a result of the knife trauma. Although the ligated parts of his iliac vein appeared congested, the lumen was smooth and contained no clot. The damaged vein was repaired with continuous 4-0 Prolene sutures (Ethicon, Inc, Somerville, NJ, USA) after the patient was systemically heparinized with 5000 units heparin. Before the sutures were finally ligated, the clamp at the cranial aspect was removed and the caudal clamp was left in place. After the backflow was clear of thrombotic debris, the clamp on his caudal iliac vein was removed and the clamp at the cranial aspect left in place. The left leg was gently massaged from calf to thigh; as a result, some thrombi in the caudal part of the vein were flushed out with the venous blood flow, and the sutures were finally ligated until the venous blood was free of thrombus. His iliac vein, although narrower after repair, was patent (Figure \n).\nAfter the operation, the patient was sent to the surgical intensive care unit with mechanical ventilation. Despite the fact that his left leg showed some signs of compartment syndrome with blisters in his calf, fasciotomy was not performed. He received systemic anticoagulation, initially with low-molecular-weight heparin, then with warfarin, titrating to an international normalized ratio (INR) between 2.0 and 2.5.Three days postoperatively, mechanical ventilation was discontinued and his signs and symptoms improved dramatically. Pulses in his left lower extremity became palpable on postoperative day 5, and the swelling and discoloration decreased. On postoperative day 30, he was taken off the OptEase® filter and the venogram showed a small amount of residual thrombus in his left external iliac vein (Figure \n). The inferior vena cava was patent, with no residual defects around the filter and no thrombus in the filter. He was discharged from the hospital in a stable condition, with full resolution of symptoms, on postoperative day 35 (Figure \nb). He was mostly asymptomatic at a recent 3-month follow-up visit except for slight edema in his left leg after walking. He continues on warfarin, maintaining an INR between 2.0 and 2.5, and wears elastic compression stockings.