A 64-year-old man with a history of obesity (BMI 38 Kg/m^2), arterial hypertension, atrial fibrillation, type 2 diabetes, chronic kidney disease, obstructive sleep apnea, and chronic venous insufficiency presented to the Emergency Department complaining of dyspnea, fever, and chest pain which started 7 days before. The patient was hypoxemic in room air (SpO2 80% and PaO2 43 mmHg). Inferior limbs appeared normal. A molecular swab formalized diagnosis of SARS-CoV2-related pneumonia. Respiratory distress progressed despite non-invasive-ventilation and hemodynamic instability requiring vasoactive support ensued. The patient was intubated and transferred to the ICU. The patient received invasive protective ventilation and hemodynamic support with noradrenaline. Gas exchange progressively worsened to a PaO2/FiO2 ratio of 70 mmHg. He developed a shock, and his lower limbs started to appear mottled. Lung and cardiac ultrasound were compatible with severe interstitial pneumonia and with no signs of pressure overload of the right heart. His coagulation profile was highly altered, as both aPTT and INR were elevated (respectively 2.28 seconds and 6.42), platelets were 164,000/mm3, and D-dimer was 117,521 UI/ml. Coagulation parameters continually worsened (), and treatment with one unit of fresh frozen plasma and vitamin K was required. Inferior limbs’ color progressively worsened, becoming frankly cyanotic, while pulses were still normal. Doppler ultrasound showed bilateral thrombosis of tibial and small saphenous veins. A continuous infusion of iloprost was started, as PCD was suspected (). Continuous infusion of unfractionated heparin was instituted, at a dose of 500-1000 IU per hour, according to aPTT, as well as continuous veno-venous hemodiafiltration as the patient developed acute kidney injury. The patient’s general conditions worsened (), and despite maximal treatment, he passed away after eight days of ICU care.
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.