Superficial venous thrombosis (SVT) 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.
A more extensive SVT may spread to the deep veins. DVT has been described to be associated with about 20% and pulmonary embolism with about 4% of SVTs that have been more than 5 cm in length.
Ultrasonography is helpful in the differential diagnostics and it is recommended to exclude DVT.
D dimer is not helpful in the differentiation between superficial and deep venous thrombosis.
An SVT (thrombophlebitis) of ≥ 5 cm in length in the lower extremity is treated with a prophylactic dose of anticoagulant therapy for 6 weeks.
Muscular vein thrombosis and SVT are often mixed up. Muscular vein thrombosis is not an SVT but a sub-category of DVT, 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
Damage to the venous intima (superficial trauma, drug infusion, intravenous use of illicit drugs)
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) 5.
Buerger's disease (i.e. thromboangiitis obliterans; picture F1), 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.
Migrating superficial thrombophlebitis (short venous cord, blocked and then cured but recurs in another part) may be a sign of an underlying malignant disease, particularly of adenocarcinoma or haematological malignancy.
Clinical picture
The affected venous area is painful, reddish and swollen. The vein is hard and tender on palpation.
An extensive SVTis often associated with fever and a mild increase in CRP concentration.
A SVT may spread to the deep veins. DVT is the more likely the closer the superficial venous thrombosis is either to the saphenofemoral junction in the groin or to the saphenopopliteal junction 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 under the skin 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.
the clinical picture is not obvious (differential diagnosis)
there are concomitant clinical signs that suggest DVT
superficial thrombophlebitis is located proximal to the knee, especially if it is close to junction of vena saphena magna, i.e. in the upper third or more proximally in the thigh (risk of thrombosis proceeding through the saphenofemoral junction to the femoral vein); or if thrombophlebitis is located in the upper part of the calf near the saphenopopliteal junction at the bend of the knee.
The aim of treatment is to alleviate local symptoms as well as to prevent thrombosis from spreading into the deep veins and embolization to lungs.
Symptoms may be alleviated with compressive stockings, cold compresses and by keeping the leg elevated.
A superficial thrombophlebitis of ≥ 5 cm in length in the lower extremity, is, according to current guidelines, treated with a prophylactic dose of anticoagulant therapy for 6 weeks.
Although there is a lack of robust research evidence on the efficacy of oral anticoagulants in the treatment of SVT, clinical practice has largely shifted to rivaroxaban 10 mg once daily or, if the patient is at increased risk of bleeding, apixaban 2.5 mg twice daily.
If the patient has, for example, a coagulation disorder or active cancer or is pregnant, low molecular weight heparin (LMWH) treatment is justified. The LMWH dose is adjusted according to the patient's weight and renal function.
In addition, topically administered NSAIDs may be used if needed.
Similar treatment is indicated if the thrombus is located (irrespective of its length) at a distance of less than 3 cm from the saphenofemoral junction located in the groin or from the saphenopopliteal junction in the popliteal area.
Some experts recommend that patients with superficial thrombophlebitis that is located close (< 3 cm) to the saphenofemoral or saphenopopliteal junction should be given similar anticoagulant treatment as in DVT. Deep Vein Thrombosis
During pregnancy, LMWH treatment is used and continued throughout pregnancy and for 6 weeks after the end of pregnancy.
If the criteria for anticoagulant therapy described above are not met, the patient may use oral NSAIDs.
NSAIDs alleviate symptoms but do not affect the process of thrombosis developing into a DVT.
Topically applied anticoagulant cream may alleviate the symptoms of a local venous thrombosis, but there is no evidence that it would prevent the spreading of the thrombosis to the deep veins.
Antimicrobial therapy is not needed and it should only be commenced if the patient clearly has another concomitant infection.
Superficial thrombophlebitis associated with an intravenous cannula is usually not treated with systemic anticoagulants. First-line treatment consists of removal of the cannula and symptom-relieving topical treatment (anticoagulant gel/ointment or diclofenac gel) and/or an oral NSAID (e.g. diclofenac 75 mg twice daily), as needed.
The patient is recommended to start moving around as soon as the symptoms allow (immobility may increase the risk of deep venous thrombosis).
A patient with an extensive or recurring superficial thrombophlebitis should be referred to specialist care.
Invasive treatment: non-urgent correction of superficial veins should be considered in a patient who has recurring venous thromboses occurring in the same area, if they are associated with varices Venous Insufficiency of the Lower Limbs. The acute-phase treatment of a SVT larger than 5 cm is pharmaceutical. Invasive treatment is not recommended in the acute phase.
Concerning the upper extremity, the available guidelines that are based on evidence only take a stand on cannula-related superficial thrombophlebitis (see above here). Due to the lack of research evidence, the treatment of other than cannula-related superficial thrombophlebitis in the upper extremity is not established. Hence, in practical clinical work, the lines of treatment of thrombophlebitis in the lower extremity may be, after clinical consideration, applied.
References
[Deep vein thrombosis and pulmonary embolism]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Cardiac Society. Helsinki: Finnish Medical Society Duodecim, 2023 (accessed 21 Mar 2024). Available in Finnish at http://www.kaypahoito.fi/hoi50022.
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