Stefano Ricci
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Abstract A 45-year-old female patient with varicose vein disease, assuming hormone therapy for dysmenorrhea treatment and awaiting a hysterectomy, underwent a duplex scanning study. She complained of pain on palpation of the medial plantar region of the left foot associated with fatigue and shortness of breath for approximately five days. She was otherwise healthy and did not have major medical problems or evidence of edema or signs of inflammation. The duplex scan showed no signs of deep venous thrombosis in the femoro-popliteal and calf veins but an acute occlusive thrombus was found in the lateral plantar veins. Lung scintigraphy findings revealed pulmonary thromboembolism. The patient was hospitalized for anticoagulant treatment and was discharged after seven days in good clinical condition. After six months duplex scanning showing partial recanalization of the plantar vein thrombosis with associated insufficiency. Plantar veins as part of the distal deep venous system have the potential to propagate a thrombus into the infrapopliteal veins. In authors' series of 11 studied patients nine had pain at the foot region, followed by edema in eight. Plantar veins were exclusively affected in nine patients, with calf compromise in two, and one with great saphenous vein thrombosis. Thrombosis extension occurred in three patients, all of them with calf pain. A high index of suspicion must be maintained for patients presenting with spontaneous unilateral foot pain. The diagnosis is usually simple and easy to make on duplex sonography, but including the plantar veins in the investigative protocol is generally not a routine procedure. Patients with symptomatic DVT or chest symptoms should be anticoagulated for three months and evaluated at the end of treatment. |
Comment by Stefano Ricci
This case report confirms the possibility that even distal thrombosis may cause PE. The rarity of the plantar thrombosis and the relatively scarce pulmonary symptomatology could suggest the condition being much more frequent and usually evolving undiscovered. The authors suggest considering these cases as fully DVT cases, by anticoagulation treatment; however, no mention is made about compression treatment of the affected limb, either for pain relief or for edema prevention/reduction. As proximal disruption of the thrombus by repeated compression of the foot determined by the musculovenous foot pump action is hypothesized. Do the Authors recommend that foot veins thrombosis patients should refrain from walking, in opposition to the current indication in DVT management?
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