Superficial venous thrombophlebitis

EBM Guidelines
16.3.2020

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.
  • 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).
  • May be associated with vasculitis.
    • Polyarteritis nodosa
    • Buerger's disease (i.e. thromboangiitis obliterans; picture «Buerger's disease in fingers»1), 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 (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)»1) 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 evd

  • 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.
  • The recommended treatment (ACCP 2012) for a superficial thrombophlebitis of ≥ 5 cm in length in the lower extremity is either a prophylactic dose of fondaparinux (2.5 mg once daily) or a mid-treatment dose of LMWH (e.g. in a patient weighing < 70 kg the dose is 6 000 IU once daily, and in a patient weighing ≥ 70 kg the dose is 7 500–8 000 IU once daily) for 6 weeks. 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.
    • Some experts recommend that patients with superficial thrombophlebitis that is located close (< 3 cm) to the saphenofemoral junction should be given similar anticoagulant treatment as in deep vein thrombosis.
  • According to the SURPRISE trial published in 2017, it seems that 6-week therapy with rivaroxaban (10 mg once daily) would not be inferior to 6-week therapy with fondaparinux (2.5 mg once daily).
    • More research is needed, but rivaroxaban therapy may already now be considered for these patients.
    • It is probably worthwhile, at least for the time being, to treat higher-risk patients (e.g. cancer patients) with parenteral anticoagulants.
    • The practicality of rivaroxaban is its benefit.
    • There is no evidence regarding other direct oral anticoagulants.
  • 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, which alleviate symptoms but do not affect the process of thrombosis developing into a deep vein thrombosis (DVT). Topically applied NSAID products can also be used as an addition to anticoagulation therapy.
  • 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.
  • Surgery appears not to be beneficial in the acute phase of superficial thrombophlebitis. 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»1.
  • Concerning the upper extremity, the available guidelines that are based on evidence only take a stand on cannula-related superficial thrombophlebitis (see above «»1). 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

  1. 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. «PMID: 22315268»PubMed
  2. 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. «PMID: 20157136»PubMed
  3. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2018;(2):CD004982. «PMID: 29478266»PubMed
  4. Scott G, Mahdi AJ, Alikhan R. Superficial vein thrombosis: a current approach to management. Br J Haematol 2015;168(5):639-45. «PMID: 25521017»PubMed
  5. 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. «PMID: 22881455»PubMed
  6. 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. «PMID: 28219692»PubMed
  7. Di Nisio M, Peinemann F, Porreca E ym. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev 2015;(11):CD011015. «PMID: 26588711»PubMed
  8. Amano M, Shimizu T. Mondor's Disease: A Review of the Literature. Intern Med 2018;57(18):2607-2612. «PMID: 29780120»PubMed.