The patient started FOLFOX chemotherapy at another
The patient started FOLFOX chemotherapy at another institute on September 14, 2015. However, he suddenly lost consciousness and his blood pressure plummeted; the electrocardiogram monitor showed ventricular tachycardia. After cardiopulmonary resuscitation, he regained spontaneous circulation and was transferred to our hospital. The laboratory data were as follows: white blood cells, 10200/μl; hemoglobin, 9.7 g/dl; platelets, 314000/μl; prothrombin time, 15.7 s; activated partial thromboplastin time (aPTT), 37.3 s; potassium, 6.3 mmol/l; blood urea nitrogen, 63 mg/dl; creatinine, 3.03 mg/dl; blood gas pH, 7.22; partial pressure of carbon dioxide, 15.4; bicarbonate, 6.4; lactate, 13.6 mmol/l; uric acid, 15.9 mg/dl. He was diagnosed with cardiogenic shock and acute kidney injury, and was subsequently provided hemodialysis. However, both of his hands became blue and swollen (Fig. 3.1). Limb ischemia due to shock was suspected. However, cyanosis and swelling of hands progressed, and cyanosis became irreversible despite stable vital signs bilateral radial improve were palpable. Thus, ischemic injury or thrombosis of small arteries was suspected. Heparin was administered by pump with hemodialysis, and was titrated to keep aPTT of 70–90s. Heparin was stopped 3 days after discontinuing hemodialysis. Laboratory tests revealed anti-thrombin III at 79.3%, protein C activity at 87.9%, and protein S antigen at 78.7%. Doppler ultrasonography showed no evident venous thrombus formation in lower extremities; however, upper extremity veins were not assessed. The patient was diagnosed with ischemic injury due to shock. Unfortunately, his lesions progressed with further swelling and bulla formation. Because of the potential development of compartment syndrome that could complicate tissue necrosis (Fig. 3.2), a surgeon was consulted who suggested fasciotomy but not angiography because of the evident gangrenous changes. Fasciotomy was arranged for both hands 12 days after initial changes were noted. On day 22, the right hand became gangrenous (Fig. 3.3), which was amputated with muscle and fasciocutaneous flaps. Pathological examination of the amputated right hand revealed that the skin and underlying soft tissue of the hand and the forearm had focal gangrenous changes with necrosis and extensive mixed leukocytic infiltrate. Verhoeff–Van Gieson staining showed multiple foci of veins with organizing as well as organized thrombi. The ulnar and radial arteries showed mild atherosclerosis with mildly thickened intima and degenerated media (Fig. 4). The patient\'s left hand remained stable after fasciotomy.
Discussion Gangrene of extremities is generally attributed to arterial occlusion or poor perfusion due to shock, whereas venous gangrene is rare. The thrombophlebitic events in venous gangrene included three distinct phases: (1) phlegmasia alba dolens, (2) phlegmasia cerulea dolens (blue thrombophlebitis), and (3) gangrene. The manifestations of phlegmasia alba dolens include edema, pain, and pale appearance (alba) of the limbs. In this phase, collateral venous circulation is partially compensated. The failure of collateral venous circulation leads to progression into the phlegmasia cerulea dolens phase. The affected extremity becomes increasingly swollen, which impedes arterial inflow; gangrene is the final stage. More than 50% of the patients with venous gangrene have underlying cancer-induced disseminated intravascular coagulation (DIC). Those of them who survive often have to undergo multiple limb amputations. A low-flow state with DIC is commonly present and may result in microcirculatory occlusion. The ischemic changes in the limbs start distally and may advance proximally, involving the proximal extremity. These changes are not usually associated with demonstrable peripheral vascular occlusive disease. The early recognition of venous thrombosis and intensive management of the underlying conditions can influence the final outcome and may prevent limb amputation. The sonography with Doppler examination is often used to survey the thrombosis in vessels. Color Doppler sonography is an accessible tool in the examination of venous thrombosis in the extremity.