"Blue phlegmasia" (phlegmasia cerulea dolens), or Gregoire's blue phlebitis, is a rare pathological condition that develops with venous thrombosis and is characterized by an extremely poor prognosis. If treatment is unsuccessful or delayed, death can occur within a few hours. In cases where hemodynamic disturbances are successfully resolved, gangrene of the extremity can result. "Blue phlegmasia" associated with venous thrombosis leads to limb amputation in 20-50% of cases and death in 25-40% of patients. An optimal therapeutic strategy has not been established.

Patient O., 40, was admitted on November 10, 2022, with signs of deep vein thrombosis in the right lower extremity. She had become ill about 24 hours earlier, when she first noticed swelling and pain in her right calf. A contrast-enhanced multislice computed tomography scan revealed bilateral segmental pulmonary embolism (PE)—occlusive iliofemoral phlebothrombosis on the right. Under local anesthesia with 5 ml of Novocaine 0.25%, aseptic conditions, with the patient in the prone position and ultrasound guidance, a popliteal vein puncture was performed. A guidewire was inserted into the vein, a 25 cm 6Fr introducer sheath was placed, and a continuous microfluidic infusion of tPA was initiated at a dose of 1 mg per hour into the guide catheter. After 24 hours: regression of the symptoms of blue phlegmasia, regression of the edema of the thigh and lower leg, relief of pain, and restoration of the physiological color of the skin. Control phlebography revealed partial lysis of thrombotic masses in the right common iliac vein, with complete lysis in the external iliac, femoral, and popliteal veins.

After 36 hours: control phlebography revealed partial lysis of thrombi in the right common iliac vein, with a mural defect enhancing contrast in the ostial area with stenosis of up to 90%. A decision was made to perform balloon angioplasty of the common iliac vein. Balloon angioplasty of the stenotic area was performed using an 10x40mm balloon catheter at a pressure of 12 atm. The exposure was 10 minutes. Control contrast enhancement revealed a suboptimal result, with a residual stenosis of 30%. Lysis was discontinued.

Conclusion: Selective intravenous catheter-directed thrombolysis has demonstrated efficacy and safety in the treatment of such a serious condition as "phlegmasia cerulea dolens." Undoubtedly, early recanalization and restoration of venous outflow are essential for the successful treatment of "phlegmasia cerulea dolens."

Dmitry Kornilov received his higher education from Samara State Medical University. I head the vascular surgery department in Nizhnevartovsk. I am a practicing surgeon with over 18 years of experience.