Phlegmasia Cerulea Dolens after Coronary Artery Bypass Surgery: What Should We Know
A 67-year-old male with a history of diabetes (hemoglobin A1c, 9.4 mg/dL) and hypertension was admitted to the Cardiology Department after presenting with Canadian Cardiovascular Society class II angina. He had no symptoms or signs of claudication, deep vein thrombosis, or hypothyroidism. His cardiac function was unremarkable, with an ejection fraction of 65%. A coronary angiogram confirmed the presence of diffuse stenosis in the left anterior descending artery and right coronary artery branch vessels. Other laboratory findings were normal, including complete blood cell counts, electrolyte levels, chemistry results, coagulation factor assays, and the results of a urinalysis. He had no other comorbidities.\nThe patient underwent elective on-pump coronary artery bypass grafting (CABG) under systemic heparinization (400 U/kg). A senior resident harvested two great saphenous veins (GSVs) from the bilateral medial calves with the thigh abducted and rotated externally and with a small pillow kept under the knee. The harvested wound tissue was simply sutured and wrapped loosely with an elastic bandage. The left internal thoracic artery was anastomosed to the left anterior descending artery following posterolateral and posterior descending artery bypass using two GSV grafts. The anesthesia, cardiopulmonary bypass (CPB), and aortic cross-clamping times were 312, 131, and 106 minutes, respectively. No adverse events occurred during the operation. The blood pressure, acid-base balance, and other parameters were all unremarkable.\nOn the first postoperative day, the patient complained of severe left calf pain immediately after extubation. His left leg was markedly swollen, violet in color, tender, and warm up to the knee. Normal Doppler sounds were identified in the dorsalis pedis artery, lateral malleolar artery, and femoral vein. However, the venous flow below the popliteal vein was obscured in the color Doppler ultrasonography, and the patient's left foot was almost paralyzed. A decreased platelet count (85,000/µL) and an increased D-dimer level (355 µg/L) were noted. Because it was believed that anticoagulation therapy and infrapopliteal thrombectomy would be ineffective at that time, a prompt four-part fasciotomy was performed to prevent irreversible neurological and muscle damage. Unfortunately, despite all of our efforts, the patient's swollen muscles became infected with Acinetobacter baumannii after 1 week (, ). A delayed skin graft was required after repeated aggressive debridement. The foot drop did not recover, and the patient was discharged 5 months postoperatively with a disability.