Superficial thrombophlebitis

Superficial thrombophlebitis or Superficial vein thrombosis (SVT) 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.[1]:826–7[2]

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).[3] Migratory superficial thrombophlebitis is known as Trousseau's syndrome.[4]

Incidence

Some 125,000 cases a year have been reported in the United States, but actual incidence of spontaneous thrombophlebitis is unknown.[5] A fourfold increased incidence from the third to the eight decade in men and a preponderance among women of approximately 55-70%.[6] The average mean age of affected patients is 60 years.[7]

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.[8]

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.[9]

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.[10] 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.[11]

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.[8]

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.[9]

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.[12]

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).[13]

Treatment with fondaparinux reduces the risk of subsequent venous thromboembolism.[14]

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.[15] 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 anitcoagulants.[16]

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.[17]

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.[18]

See also

References

  1. ↑ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 0-7216-2921-0.
  2. ↑ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0.
  3. ↑ Ann Intern Med 2010; 152:218 / Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study / Decousus H., et al.
  4. ↑ Creager, Mark; Loscalzo, Joseph; Beckman, Joshua A. (30 August 2012). Vascular Medicine: A Companion to Braunwald's Heart Disease. Elsevier Health Sciences. p. 141. ISBN 9781455737369.
  5. ↑ Blumenberg RM, et al. / Occult deep venous thrombosis complicating superficial thrombophlebitis / J Vasc Surg. 1998;27:338-343
  6. ↑ Coon WW, et al. / Venous thromboembolism and other venous disease in the Tecumseh community health study / Circulation 1973;48;839-846
  7. ↑ Decousus H., et al. / Superficial vein thrombosis: risk factors, diagnosis, and treatment/ Curr Opin Pulm Med 2003;9:393-397
  8. 1 2 Karwowski, J., et al. / How to manage thrombophlebitis of the lower extremities / J of Fam Prac 2013:554-558
  9. 1 2 Fernandez, L., et al. / Superficial thrombophlebitis of the lower extremity / uptodate.com 2010
  10. ↑ Decousus H., et al. / Superficial vein thrombosis: risk factors, diagnosis, and treatment / Curr Opin Pulm Med. 2003;9:393-397
  11. ↑ Fernandez, L., et al. / Superficial thrombophlebitis of the lower extremity / uptodate.com 2012
  12. ↑ Superficial Thrombophlebitis Treated By Enoxaparin Study Group/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./Arch Intern Med. 2003;163(14):1657.
  13. ↑ Kearon C., et al./Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)/Chest 2008;133:454S
  14. ↑ Di Nisio, M; Wichers, IM; Middeldorp, S (Mar 14, 2012). "Treatment for superficial thrombophlebitis of the leg.". Cochrane database of systematic reviews (Online). 3: CD004982. doi:10.1002/14651858.CD004982.pub4. PMID 22419302.
  15. ↑ Karwowski, J., et al./How to manage thrombophlebitis of the lower extremities/ J of Fam Prac 2013;552-558
  16. ↑ Belcaro G., et al./Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study/Angiology 1999;50:523
  17. ↑ Davidovic L., et al./Indications for surgical treatment of acute superficial thrombophlebitis/Srp Arh Celok 1990;118:471
  18. ↑ Decousus H., et al./Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study/Ann Intern Med. 2010;152(4):218-224
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