Iliofemoral DVT and phlegmasia

Synopsis

Recognise extensive iliofemoral thrombosis, rescue phlegmasia and select patients safely for early thrombus removal.

A blue, massively swollen, severely painful leg with sensory or motor loss or shock is phlegmasia until proved otherwise: resuscitate and obtain immediate vascular review.
Initial management is prompt weight-adjusted UFH or LMWH, aggressive elevation and fluid resuscitation, with urgent assessment for thrombus removal and fasciotomy if compartment syndrome develops.
For stable symptomatic iliofemoral DVT consider catheter-directed thrombolysis only when symptoms are under 14 days, function is good, life expectancy is at least 1 year and bleeding risk is low.

Key red flags

Rapid cyanosis, tense whole-limb swelling and severe pain indicates phlegmasia.

Sensory loss, weakness, poor refill or absent Doppler signals suggests threatened viability.

Hypotension, oliguria, lactate rise or collapse indicates systemic compromise.

Active bleeding or intracranial haemorrhage changes the rescue technique but not urgency.

Iliofemoral pattern

Whole-leg swelling from groin distally, groin or back pain and superficial collaterals suggests central outflow obstruction.

Phlegmasia cerulea

Sudden ischaemic pain, cyanosis, functional loss, tachycardia or shock indicates near-total venous obstruction.

Threatened viability

Sensory loss, weakness, tense compartments and diminished arterial signals indicate compromised tissue perfusion.

Pulmonary embolism

Dyspnoea, chest pain, haemoptysis, syncope or hypotension requires urgent PE assessment.

Investigation priorities

Urgent duplex ultrasoundFirst step

Confirm proximal thrombosis and accessible anatomical extent.

Management branches

Worked case: phlegmasiaRescue threatened limb

An adult has cyanosis, tense swelling, sensory loss and hypotension with extensive iliofemoral thrombosis.

Begin ABC resuscitation, obtain large-bore access, bloods and crossmatch and summon vascular, interventional and anaesthetic teams.
Elevate the limb, replace intravascular volume and give weight-adjusted heparin unless a contraindication requires another senior plan.

Stable intervention pathwayApply four criteria

A stable patient has symptomatic iliofemoral DVT without threatened limb signs.

Key medicines

Enoxaparin sodiumFor iliac thrombosis give 100 IU/kg (1 mg/kg) subcutaneously every 12 hours; at CrCl 15–30 mL/min use 1 mg/kg subcutaneously once daily.Contraindicated with active significant bleeding or immune-mediated HIT within 100 days. Not recommended below CrCl 15 outside dialysis-circuit use. Pregnancy dosing follows early-pregnancy weight; plan neuraxial timing and continue through the obstetric duration endpoint.

ApixabanFor an eligible stable non-pregnant adult give 10 mg orally twice daily for 7 days then 5 mg twice daily; review at 3 months and use 2.5 mg twice daily only after 6 months for selected extended prevention.Avoid active bleeding and hepatic coagulopathy. Use cautiously at CrCl 15–29 and not below 15 mL/min or in dialysis. Avoid pregnancy and make a breastfeeding-versus-treatment decision. Coordinate interruption around invasive treatment.

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