Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report

Background COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both. Case presentation A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated. Conclusions This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

An interesting case of an atraumatic painful swollen limb in a pregnant woman

Phlegmasia cerulea dolens is an uncommon complication of deep venous thrombosis. This is associated with high rates of morbidity if not treated effectively. We present a young lady 13 weeks pregnant with one-day history of left lower limb swelling with pain and discolouration. Bedside ultrasonography revealed thrombosis occluding the common femoral vein and collateral femoral vein. She had history of neonatal alloimmune thrombocytopaenia (NAIT), and had immunotherapy previously. The safest option was to give low molecular weight heparin (LMWH) on an inpatient basis. Anticoagulation with LMWH has been well established as thromboprophylaxis during pregnancy, however, the safety profile of systemic anticoagulation is matter of debate. As highlighted in this scenario the management needs to be tailored on an individual basis. The cause for the extensive deep vein thrombosis could be possibly due to the recent immunoglobulin therapy, undiagnosed prothrombotic state (outwith pregnancy) or the procoagulant state associated with pregnancy.