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Superficial Venous Thrombophlebitis

Essentials

  • Thrombophlebitis is a common disease of the superficial veins that most commonly occurs in the lower extremities (especially in the great saphenous vein [vena saphena magna]) and often is connected with varicose veins. It can also occur elsewhere, e.g. on the neck (external jugular vein), on the chest (Mondor's disease) or in the upper extremities.
  • As opposed to deep vein thrombosis (DVT), an inflammatory process of the venous wall is almost always present in addition to thrombosis.
  • The prognosis of superficial thrombophlebitis is usually good.
  • A more extensive superficial venous thrombosis may spread to the deep veins. Deep venous thrombosis has been described to be associated with about 20% and pulmonary embolism with about 4% of superficial venous thromboses that have been more than 5 cm in length.
  • Ultrasonography is helpful in the differential diagnostics and it is recommended to exclude deep vein thrombosis http://www.dynamed.com/condition/superficial-vein-thrombosis-svt#TESTING_OVERVIEW.
  • D dimer is not helpful in the differentiation between superficial and deep venous thrombosis.
  • A superficial thrombophlebitis of ≥ 5 cm in length in the lower extremity, is according to current guidelines treated with a prophylactic dose of fondaparinux or with a mid-treatment dose of LMWH for 6 weeks. In addition, topically administered NSAIDs may be used if needed. Tentatively, oral rivaroxaban seems to be promising.
  • The treatment of superficial thrombophlebitis elsewhere is not equally well established.
  • Muscular vein thrombosis and superficial thrombophlebitis are often mixed up. Muscular vein thrombosis is not a superficial thrombophlebitis but a sub-category of deep vein thrombosis, in which the thrombosis is located in the muscular veins of the calf region (plexus soleus or plexus gastrocnemius).

Predisposing and aetiological factors

  • Predisposing factors include damage to the venous intima (superficial trauma, drug infusion, intravenous use of illicit drugs), decreased venous flow (varices, chronic venous insufficiency, pregnancy, prolonged immobilization), increased thrombotic tendency (malignancy, coagulation disorder, hormonal therapy) or a combination of these.
  • The condition may also appear without any clear predisposing factor.
  • Mondor's disease is a rare, usually benign thrombophlebitis that heals spontaneously within 4-8 weeks. Mondor's disease typically manifests in other parts of the body than the lower extremity (in the chest wall, for example) 8.
  • May be associated with vasculitis.
    • Polyarteritis nodosa
    • Buerger's disease (i.e. thromboangiitis obliterans; picture ), usually affects the small and medium-sized arteries in smokers. Approximately one third of these patients also have superficial venous thrombi. Recurring superficial venous thrombi in a young person who smokes much suggest Buerger's disease.
    • Behcet's disease
  • Migrating superficial thrombophlebitis http://www.dynamed.com/condition/superficial-vein-thrombosis-svt#TROUSSEAU_SYNDROME (short venous cord, blocked and then cured but recurs in another part) may be a sign of an underlying malignancy, particularly of pancreatic cancer.

Clinical picture

  • The affected venous area is painful, reddish and swollen. The vein is hard and tender on palpation.
  • An extensive phlebitis often is associated with fever and a mild increase of CRP concentration.
  • A superficial venous thrombosis may spread to the deep veins. Deep vein thrombosis is the more likely the closer the superficial thrombophlebitis is either to the saphenofemoral junction in the groin or to the perforant veins in the popliteal area.
  • The clinical picture is often benign and self-limiting. The inflammation and the symptoms take usually 3-4 weeks to resolve, but sometimes the condition may become prolonged. The thrombosed vein may be felt for months.
  • Superficial venous thrombosis may recur, particularly if it was associated with varices.

Diagnosis

  • The diagnosis is based on clinical examination.
  • The determination of the D dimer concentration is not helpful in the differentiation between superficial and deep venous thrombosis.
  • Ultrasonography (video Superficial Thrombophlebitis (Ultrasonography)) is recommended to confirm the diagnosis and to exclude deep venous thrombosis.
  • Ultrasonography is indicated at least, if
    • the clinical picture is not obvious (differential diagnosis)
    • there are concomitant clinical signs that suggest deep venous thrombosis
    • superficial thrombophlebitis is located proximal to the knee, especially if it is close to junction of vena saphena magna, i.e. above the mid-thigh (risk of thrombosis proceeding through the saphenofemoral junction to the femoral vein; ACCP 2012); or if thrombophlebitis is located in the upper part of the calf near the perforant veins at the bend of the knee that empty into the popliteal vein.
    • the patient is pregnant.

Treatment Treatment for Superficial Thrombophlebitis of the Leg, Slow Versus Fast Subcutaneous Injection of Lmwh

    References

    • Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S-94S. [PubMed]
    • Decousus H, Quéré I, Presles E et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010;152(4):218-24. [PubMed]
    • Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2018;(2):CD004982. [PubMed]
    • Scott G, Mahdi AJ, Alikhan R. Superficial vein thrombosis: a current approach to management. Br J Haematol 2015;168(5):639-45. [PubMed]
    • Tait C, Baglin T, Watson H et al. Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol 2012;159(1):28-38. [PubMed]
    • Beyer-Westendorf J, Schellong SM, Gerlach H ym. Prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: the open-label, randomised, non-inferiority SURPRISE phase 3b trial. Lancet Haematol 2017;4(3):e105-e113. [PubMed]
    • Di Nisio M, Peinemann F, Porreca E ym. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev 2015;(11):CD011015. [PubMed]
    • Amano M, Shimizu T. Mondor's Disease: A Review of the Literature. Intern Med 2018;57(18):2607-2612. [PubMed].