Beyond Deep Vein Thrombosis: Early Recognition of Phlegmasia Cerulea Dolens With Arterial Inflow Compromise and Concomitant Pulmonary Embolism.

Phlegmasia cerulea dolens (PCD) is a rare and severe complication of extensive deep vein thrombosis (DVT) that can rapidly progress to limb ischemia, venous gangrene, and death. Early recognition and restoration of venous outflow are, therefore, critical. We report the case of a 48-year-old man who presented with a three-day history of progressive left lower-limb swelling, pain, and bluish discoloration. Examination revealed tense swelling of the entire limb, delayed capillary refill, and a diminished dorsalis pedis pulse. Duplex ultrasonography demonstrated extensive left iliofemoral and popliteal DVT. Computed tomography (CT) angiography showed absent distal arterial opacification without primary arterial occlusion, consistent with arterial inflow compromise secondary to severe venous congestion. Despite the absence of cardiopulmonary symptoms or hemodynamic instability, CT pulmonary angiography demonstrated acute right lower-lobe segmental pulmonary emboli. The patient underwent therapeutic anticoagulation, inferior vena cava filter placement, and ultrasound-assisted catheter-directed thrombolysis, followed by mechanical thrombectomy and high-pressure venous angioplasty for persistent thrombus. Intravascular ultrasound confirmed satisfactory luminal expansion and excluded May-Thurner syndrome. Completion venography demonstrated restoration of brisk venous flow, with subsequent clinical improvement and preservation of limb viability. This case highlights the importance of early recognition of PCD in patients presenting with a painful, swollen, cyanotic limb. Severe venous congestion in PCD can reduce distal arterial inflow even without primary arterial occlusion. Pulmonary embolism may also occur without respiratory symptoms or hemodynamic instability. Prompt anticoagulation, urgent multidisciplinary assessment, and timely escalation to endovascular thrombus removal may be critical for successful limb salvage.