HEMORRHAGIC BULLAE AS A PRESENTATION OF PHLEGMASIA CERULEA DOLENS WITH MAY-THURNER SYNDROME H. Bernstein BS, M. La MD, J. Tien MD, H. Shi MD, S. J. Cossich MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: May Thurner syndrome is a severe variant of venous thromboembolism (VTE) where the iliac vein is extrinsically compressed by the arterial system, vertebrae, or other bony structures. Symptoms include extremity pain, swelling, and skin discoloration and ulceration due to venous insufficiency. Phlegmasia Cerulea Dolens (PCD) is a severe complication of VTE where compartment syndrome can occur due to the swelling of the extremity. CASE: A 54-year old man with dementia and chronic kidney disease presented with bilateral lower extremity swelling and blistering. Examination revealed multiple tense fluid filled bullae in medial lower leg to the foot on his right and left lower extremities. They were primarily located in the distribution of saphenous veins. Femoral pulses were palpable, dorsalis pedis and posterior tibial pulses were only observed by Doppler ultrasound. A venous Doppler ultrasound study showed extensive occlusive thrombus in the left common femoral, superficial femoral, greater saphenous, and popliteal veins. A heparin dripwas initiated. Findings froma CT of the lower extremitywere concerning for phlegmasia dolens given extensive iliofemoral thrombosis and May-Thurner syndrome. Vascular surgery performed urgent mechanical thrombectomy and stenting of the left common iliac, external iliac, common femoral, and popliteal veins. Intravascular ultrasound (IVUS) confirmed aortic bifurcation compression on caval bifurcation as well as left common iliac vein compression between right common iliac and spine. He was discharged on apixiban. DISCUSSION: Skin findings from extensive VTE and PCD are often nonspecific. Marked swelling and cyanosis of the limb can occur. More often, techniques such as ultrasonography are performed to evaluate venous status. We demonstrate one of the few cases where acute on chronic VTE, including blockage of a large proximal vein, led to formation of large bullae and blistering. We hypothesized that these findings resulted from a change in venous return due to interstitial fluid hydrostatic pressure which lead to separation of epidermal cells. The treatment strategy initially involves anticoagulation, then subsequent angioplasty and stenting if applicable. Quick relief of the obstruction is key to avoiding future limb amputation.
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