A 74-year-old man presented to the emergency department after a motorcycle accident. He had a deformity in the right leg. His comorbidities were chronic obstructive pulmonary disease, ischemic cardiomyopathy due to myocardial infarction, atrial fibrillation, hypertension, and dyslipidemia. His medications included aspirin and clopidogrel. Following investigations in this admission, a brain computed tomography (CT) revealed that he had acute traumatic subdural hematoma that was managed with nonoperative treatment. His right leg was broken, which was diagnosed as a closed fracture of the tibia and fibula, and was managed conservatively. He had fractures at the left iliac crest and the left superior pubic rami. The neurovascular conditions were normal. During admission, he had acute dyspnea with desaturation but no chest pain at ten days after admission. On examination, his blood pressure was 102/78 mmHg, pulse rate was 100/min, respiratory rate was 24/min, and blood oxygen saturation (SpO2) was 90% in room air, which was not corrected with oxygen supplement. He had crepitation at his left lower lung but no wheezing. CT angiography of the chest was performed and showed acute PEs at the right superior and inferior trunk. He was found to have acute respiratory failure and hypotension after the chest CT angiography was finished. He was scheduled for an emergency operation for surgical pulmonary embolectomy.\nOn the next day at the surgical intensive care unit (ICU), he developed progressive left leg edema with cyanosis. He had no fever and he could still move his leg, but his pain could not be evaluated since he was delirious. On examination, his left lower limb exhibited discoloration at his left foot without any ulcer or bleb, moist skin, or pitting edema, and the left dorsalis pedis and posterior tibial pulse could be palpated (1+) but were diminished (). The motor functions remained intact. Doppler ultrasonography was performed and revealed an uncompressible vein along the midsuperior femoral vein to the popliteal vein. His laboratory investigation showed that the leukocytosis and creatinine level rose from 1.04 mg% to 1.62 mg% and creatinine phosphokinase (CPK) was 322 U/L. He was diagnosed with PCD at the left femoral vein. The intervention radiologist attempted a catheter-directed thrombectomy, but it failed because the guider could not pass through the intraluminal clot. The patient was scheduled for emergency operation again for surgical thrombectomy with fasciotomy of the left leg (). The operative finding was a thrombus in the femoral vein that was 10 cm in length (). The compartment pressures before performing the fasciotomy at the anterior, lateral, and superficial posterior compartments were 43 mmHg, 37 mmHg, and 47 mmHg, respectively. The deep posterior compartment pressure was not measured. After the operation, his pain was relieved and the left dorsalis pedis and posterior tibial pulse were normal. He continued on wound dressings and the fasciotomy was closed by split-thickness skin graft. He continued on oral anticoagulant drugs for six months and underwent elective ray amputation at five months after the PCD for a dry gangrenous left big toe.
A Hispanic 58-year-old female with a past medical history of gastritis arrived into the emergency room (ER) with acute onset severe pain on the left leg associated with discoloration of the leg. According to the patient, approximately three hours prior to her arrival to the ER, she was walking when, suddenly, she started experiencing sharp pain in her left leg which rapidly progressed. The physical examination was remarkable for left lower extremity pain, discoloration, edema, associated with tenderness to touch, diminished distal pulses, and reduce sensation and mobility throughout the leg, which can be appreciated below (Figure ).\nWithin the first 30 min after her arrival to the hospital, a pressure Doppler was performed where extensive deep vein thrombosis (DVT) (left femoral-popliteal venous thrombosis) (Figure ) diagnosis was made and within the subsequent 60 min, a computed tomography angiography (CTA) aorto-ilio-femoral runoff with delayed phase was performed, showing delayed opacification of arterial segments below the knee level (Figure ), confirming the diagnosis. A bolus of heparin was given, followed by an infusion. Thrombolysis was offered to the patient, however, she refused due to concern for side effects.\nAfter one hour of starting heparin infusion, blood flow to the leg was regained and the patient recovered full sensation and movement in the leg; coloration returned to normal in the affected leg. The patient was admitted for continued observation and discharged later on direct oral anticoagulants (DOACs) without any recurrence of DVT so far.\nThe patient denied recent flights, a sedentary lifestyle, surgery, trauma, alcohol, tobacco, and drug use. There was neither a previous episode nor a family history of similar symptoms to her knowledge. Age-appropriate oncology screening was negative; mammogram from June 2020 was normal; colonoscopy four years before the presentation was also negative; Pap smears as well. Thrombophilia workup done by the Hematology/Oncology service was unrevealing, leading to a diagnosis of unprovoked DVT.\nThe curious part of the case is that even though thrombolysis and thrombectomy are considered the gold standard in the treatment of PCD, this patient had a spontaneous recovery only with heparin which serves as the only purpose to prevent the propagation of the thrombus. This specific patient according to Rutherford limb ischemia classification [] was a IIb which granted surgical intervention. Still, it remains unclear how such an extensive DVT improved in so quick fashion without thrombectomy/thrombolysis but seems that early use of heparin might have played an important role in the evolution of this patient's case and that early use of heparin might decrease the need for surgical intervention in some patients.