Abstract
Phlegmasia alba dolens (PAD) is a rare manifestation of extensive iliofemoral deep venous thrombosis characterized by near-complete venous outflow obstruction, resulting in severe pain, diffuse limb swelling, and pallor, whereas arterial inflow remains preserved. PAD is a vascular emergency as progression to phlegmasia cerulea dolens and venous gangrene may occur without prompt restoration of venous outflow. A 62-year-old man with a past medical history of prostate cancer status post prostatectomy presented with dyspnea, chest pain, and acute right lower extremity swelling 1 week after inflatable penile prosthesis implantation. He denied a history of prior pelvic radiation or leg swelling. Computed tomography pulmonary angiography demonstrated bilateral pulmonary emboli with right heart strain. Duplex ultrasound imaging confirmed thrombosis of the right common femoral and profunda femoris veins. Cross-sectional imaging revealed the prosthetic reservoir compressing the right external iliac vein. The patient underwent catheter-directed mechanical thrombectomy for pulmonary emboli, followed by venography via right popliteal access, demonstrating extensive iliofemoral thrombosis with near-complete iliac venous outflow obstruction. After thrombectomy of the iliac venous system, persistent 90% stenosis of the right external iliac vein was identified because of extrinsic compression from the prosthetic reservoir. Balloon angioplasty was ineffective. Intravascular ultrasound imaging-guided placement of two self-expanding venous stents (Abre 16 × 120 mm and 16 × 60 mm) restored brisk flow into the inferior vena cava. An inferior vena cava filter was placed. The patient improved clinically and was discharged on anticoagulation with planned urologic revision. Extrinsic compression of the external iliac vein by penile prosthesis reservoir malposition is a rare but important cause of PAD. Endovascular thrombectomy and stenting can successfully restore venous outflow and prevent limb loss.