Superficial thrombophlebitis

Superficial thrombophlebitis is a thrombosis and inflammation of superficial veins which presents as a painful induration with erythema, often in a linear or branching configuration forming cords.[2]:826–7[3]

Superficial thrombophlebitis
Other namesSuperficial vein thrombosis (SVT)
Superficial thrombophlebitis as seen by ultrasound[1]

Superficial thrombophlebitis is due to inflammation and/or thrombosis, and less commonly infection of the vein. It is generally a benign, self-limited disorder, however, it can be complicated by deep vein thrombosis (DVT) and even pulmonary embolism (PE)[4] Migratory superficial thrombophlebitis is known as Trousseau's syndrome.[5]

Signs and symptoms

Findings of tenderness, induration, pain and/or erythema along the course of a superficial vein usually establish a clinical diagnosis, especially in patients with known risk factors. In addition, there is often a palpable, sometimes nodular cord, due to thrombus within the affected vein. Persistence of this cord when the extremity is raised suggests the presence of thrombus.[6]

Complications

Superficial vein thrombosis extension to the deep vein system and/or recurrence of SVT.

Suppurative thrombophlebitis is suspected when erythema extends significantly beyond the margin of the vein and is likely to be associated with significant fever. If suspected, antibiotic treatment, surgical drainage and potentially vein excision are indicated.[7]

Venous thromboembolism can occur with superficial vein thrombosis. Estimates of the percentage of patients with SVT who also have DVT vary between 6% and 53%, and symptomatic pulmonary embolism has been reported in 0% to 10% of patients with SVT.[4]

Risk factors

Patient characteristics and predisposing factors for thrombophlebitis nearly mirror those for DVT; thrombophlebitis is a risk factor for the development of DVT, and vice versa.[8] Lower extremity superficial phlebitis is associated with conditions that increase the risk of thrombosis, including abnormalities of coagulation or fibrinolysis, endothelial dysfunction, infection, venous stasis, intravenous therapy and intravenous drug abuse.[6]

Diagnosis

Clinical evaluation is the primary diagnostic tool for thrombophlebitis. Patients with thrombophlebitis complain of pain along the affected area. Some report constitutional symptoms such as low grade fever and aches. On physical examination, the skin over the affected vein exhibits erythema, warmth, swelling, and tenderness. Later in the disease, as induration subsides, erythema gives way to a ruddy or bruised color.[9]

Duplex ultrasound identifies the presence, location and extent of venous thrombosis, and can help identify other pathology that may be a source of the patient's complaints. Ultrasound is indicated if superficial phlebitis involves or extends into the proximal one-third of the medial thigh, there is evidence for clinical extension of phlebitis, lower extremity swelling is greater than would be expected from a superficial phlebitis alone or diagnosis of superficial thrombophlebitis in question.[6]

Treatment

Treatment with compression stockings should be offered to patients with lower extremity superficial phlebitis, if not contraindicated (e.g., peripheral artery disease). Patients may find them helpful for reducing swelling and pain once the acute inflammation subsides.

Nonsteroidal anti-inflammatory drugs (NSAID) are effective in relieving the pain associated with venous inflammation and were found in a randomized trial to significantly decrease extension and/or recurrence of superficial vein thrombosis.[10]

Anticoagulation for patients with lower extremity superficial thrombophlebitis at increased risk for thromboembolism (affected venous segment of ≥5 cm, in proximity to deep venous system, positive medical risk factors).[11]

Treatment with fondaparinux reduces the risk of subsequent venous thromboembolism.[12]

Surgery reserved for extension of the clot to within 1 cm of the saphenofemoral junction in patients deemed unreliable for anticoagulation, failure of anticoagulation and patients with intense pain.[9] Surgical therapy with ligation of saphenofemoral junction or stripping of thrombosed superficial veins appears to be associated higher rates of venous thromboembolism compared with treatment with anticoagulants.[13]

Epidemiology

Some 125,000 cases a year have been reported in the United States, but actual incidence of spontaneous thrombophlebitis is unknown.[14] A fourfold increased incidence from the third to the eight decade in men and a preponderance among women of approximately 55-70%.[15] The average mean age of affected patients is 60 years.[8]

Thrombophlebitis can develop along the arm, back, or neck veins, the leg is by far the most common site. When it occurs in the leg, the great saphenous vein is usually involved, although other locations are possible.[9]

See also

References
  1. Smith B (27 March 2015). "UOTW #42". Ultrasound of the Week. Retrieved 27 May 2017.
  2. James WD, Elston DM, Berger TG, Andrews GC (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 978-0-7216-2921-6.
  3. Rapini RP, Bolognia JL, Jorizzo JL (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
  4. Decousus H, Quéré I, Presles E, Becker F, Barrellier MT, Chanut M, Gillet JL, Guenneguez H, Leandri C, Mismetti P, Pichot O, Leizorovicz A (February 2010). "Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study". Annals of Internal Medicine. 152 (4): 218–24. doi:10.7326/0003-4819-152-4-201002160-00006. PMID 20157136.
  5. Creager M, Loscalzo J, Beckman JA (30 August 2012). Vascular Medicine: A Companion to Braunwald's Heart Disease. Elsevier Health Sciences. p. 141. ISBN 9781455737369.
  6. Fernandez L, Scovell S, Eidt JF, Mills JL, Collins KA (2011). "Superficial thrombophlebitis of the lower extremity". UpToDate. Waltham, MA.
  7. Davidović L, Kostić D, Lotina S, Cinara I (1990). "[Indications for surgical treatment of acute superficial thrombophlebitis]". Srpski Arhiv Za Celokupno Lekarstvo. 118 (11–12): 471–3. PMID 2133604.
  8. Decousus H, Epinat M, Guillot K, Quenet S, Boissier C, Tardy B (September 2003). "Superficial vein thrombosis: risk factors, diagnosis, and treatment". Current Opinion in Pulmonary Medicine. 9 (5): 393–7. doi:10.1097/00063198-200309000-00009. PMID 12904709.
  9. Karwowski JK (November 2007). "How to manage thrombophlebitis of the lower extremities: why this malady warrants close attention". Contemporary Surgery. 63 (11): 552–8.
  10. Superficial Thrombophlebitis Treated By Enoxaparin Study Group (July 2003). "A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis". Archives of Internal Medicine. 163 (14): 1657–63. doi:10.1001/archinte.163.14.1657. PMID 12885680.
  11. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ (June 2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 454S–545S. doi:10.1378/chest.08-0658. PMID 18574272.
  12. Di Nisio M, Wichers IM, Middeldorp S (February 2018). "Treatment for superficial thrombophlebitis of the leg". The Cochrane Database of Systematic Reviews. 2: CD004982. doi:10.1002/14651858.CD004982.pub6. PMC 6491080. PMID 29478266.
  13. Belcaro G, Nicolaides AN, Errichi BM, Cesarone MR, De Sanctis MT, Incandela L, Venniker R (July 1999). "Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study". Angiology. 50 (7): 523–9. doi:10.1177/000331979905000701. PMID 10431991.
  14. Blumenberg RM, Barton E, Gelfand ML, Skudder P, Brennan J (February 1998). "Occult deep venous thrombosis complicating superficial thrombophlebitis". Journal of Vascular Surgery. 27 (2): 338–43. doi:10.1016/S0741-5214(98)70364-7. PMID 9510288.
  15. Coon WW, Willis PW, Keller JB (October 1973). "Venous thromboembolism and other venous disease in the Tecumseh community health study". Circulation. 48 (4): 839–46. doi:10.1161/01.cir.48.4.839. PMID 4744789.
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