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  • Venous gangrene treatment is based on therapeutic anticoagul

    2019-06-19

    Venous gangrene treatment is based on therapeutic anticoagulation and thrombolytic therapy. Low-molecular weight heparin is a good choice for patients with active cancer and for pregnant women with good renal function, whereas heparin is used as an alternative in patients with poor renal function. Most clinicians favor heparin as it buy Z-Ligustilide can be monitored directly and the potential for under-administration can be avoided. Anticoagulation can prevent thrombosis propagation but has little impact on reducing the thrombus size. More invasive albeit feasible strategies are systemic thrombolysis and percutaneous catheter-directed thrombolysis (CDT), which involves the administration of plasminogen-activating agents directly into the blood clot, and percutaneous mechanical thrombectomy (PMT). The rate of clot lysis by CDT was better than in the combination treatment using heparin and warfarin therapy (72% vs 12% patency rate at 6 months). Conversely, the combination treatment using CDT and PMT showed success in 80–90% of the patients. The role of combined CDT and PMT treatment need further investigation to confirm the combination was superior to CDT alone, which was shown to be effective in reducing the incidence of thrombolysis-related pulmonary embolism. Some surgeons suggest fasciotomy in patients with venous gangrene complicated with compartment syndrome-induced tissue edema that can compromise flow into a limb. Amputation should be the last resort because auricle is difficult to distinguish viable tissue from nonviable tissue. The early recognition of venous gangrene is important as the use of anticoagulant drugs and thrombolytic therapy might save the limb from amputation. The anticoagulant agent is the first choice. However, if limb cyanosis develops, CDT or CDT plus PMT may be considered as salvage therapy. In our case, the patient received chemotherapy for colorectal cancer and developed tumor lysis syndrome. He suffered from ventricular tachycardia with cardiogenic shock and received resuscitation. Although he was first diagnosed with limb ischemia due to cardiogenic shock, the swelling and cyanosis gradual progressed despite normal blood pressure. The differential diagnosis of wet gangrene includes venous thrombosis and infection by putrefying bacteria. Venous thrombosis was considered as the most likely diagnosis. Potential underlying causes of venous gangrene in our case were cardiogenic shock and cancer-related chronic DIC, which were shown to precipitate venous gangrene in previous studies. The tumor lysis syndrome might have aggravated this patient\'s venous gangrene. The unique presentation of our case illustrates the possibility of venous gangrene developing in patients with metastatic colorectal cancer following chemotherapy.
    Conflict of interest