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.
A 21-year-old female college student presented to the emergency department (ED) with severe pain in her left hip, thigh, and calf. The pain started suddenly when she was playing basketball a few hours earlier. She twisted her torso to shoot the ball and heard a “pop” in her left hip with immediate onset of pain, and she subsequently fell to her knees. She was initially able to ambulate but had worsening pain and rapid progression of swelling and mottling in the left leg from her hip to her ankle. She denied any pain or swelling in that extremity prior to the injury during the basketball game. With the exception of oral contraceptive use, she had no significant medical or family history.\nOn examination her left extremity was mottled, dusky, and cool to the touch from the hip to the toes and she had decreased dorsalis pedis and posterior tibial pulses when compared with the right extremity. The leg was markedly tender to palpation and sensation to light touch was diminished. Passive range of motion of the hip, knee, and ankle elicited severe pain.\nPOCUS was performed at the bedside to evaluate for arterial blood flow and deep venous thrombosis. This demonstrated normal color flow in the femoral and popliteal arteries (), but echogenic material was noted within the left common femoral vein extending distally to the popliteal vein and the veins were non-compressible (). Vascular surgery was immediately consulted, and while awaiting their arrival to the ED the patient was sent for an emergent computed tomography (CT) angiogram, which confirmed arterial patency and extensive deep venous thrombosis in the left popliteal, femoral, and iliac veins (). A heparin bolus was given and the patient was then taken to interventional radiology where she underwent partial thrombectomy, catheter-directed tissue plasminogen activator (tPA) treatment, and placement of an inferior vena cava (IVC) filter. By the next morning her leg was noted to be well-perfused, non-tender, and without swelling, and her pain had resolved. A workup for hypercoagulable states revealed heterozygosity for the Factor V Leiden mutation. She was discharged one week later on warfarin after bridging from enoxaparin.