Practice: Superficial Thrombophlebitis (Superficial Venous Thrombosis)

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BMJ 2015;350:h2039 doi: 10.1136/bmj.

h2039 (Published 22 June 2015) Page 1 of 4

Practice

PRACTICE

PRACTICE POINTER

Superficial thrombophlebitis (superficial venous


thrombosis)
H Nasr specialist registrar, J M Scriven consultant vascular surgeon
Department of Vascular Surgery, Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK

Superficial thrombophlebitis (increasingly being called


superficial venous thrombosis) is inflammation of the superficial What are the causes of superficial
veins associated with venous thrombosis. Traditionally, it has thrombophlebitis?
been considered a benign, self limiting disease of the lower
extremity. However, it can affect most superficial venous Superficial thrombophlebitis shares the same aetiological factors
systems in the body and importantly can be associated with as other thrombotic disorders; it can also develop “de novo.”
deep vein thrombosis and pulmonary embolism. Treatment is Prolonged immobility, a hypercoagulable state, or trauma to a
aimed at symptomatic control and prevention of these serious vessel wall (such as with intravenous cannulation) may
and potentially fatal complications. Treatment options are predispose to thrombophlebitis. Previous episodes of superficial
variable and controversial. thrombophlebitis with or without deep vein thrombosis
predispose to subsequent episodes, but varicose veins remain
How common is superficial the most important clinically identifiable risk factor. Other risk
thrombophlebitis? factors include prolonged travel, recent surgery, pregnancy,
oestrogen based hormone therapy, and malignancy (5–20%).7
The incidence of superficial thrombophlebitis remains unclear
Varicose veins are by far the most common aetiological factor,
but is thought to be higher than that of deep vein thrombosis,
in up to 88% of cases.7
which is estimated at about one per 1000.1 Although age is not
an independent risk factor, the incidences of other risk factors
increase with age, making superficial thrombophlebitis more Superficial thrombophlebitis and varicose
common in older people, and more common in women veins
(50–70%).2-4 However, complications are less likely in those The prevalence of superficial thrombophlebitis in patients with
over 60 years old.5 varicose veins ranges from 4% to 59%2 8 9 and is more common
in the great saphenous system rather than the small saphenous
How is it diagnosed? system. This relationship between superficial thrombophlebitis
and varicose veins means that superficial thrombophlebitis is
Superficial thrombophlebitis is a clinical diagnosis. Patients an indication for consideration of varicose vein treatment;
usually present with pain and discoloration (redness in the acute primary care practitioners should refer such patients to a
phase progressing to a brown, haemosiderin based pigmentation specialist (such as a vascular surgeon) for an opinion regarding
over days to weeks) over the affected superficial veins (fig 1⇓). treatment of varicose veins.10
On palpation, the vein is tender and hard. Extensive limb
swelling should raise the suspicion of deep vein thrombosis
What are the types of superficial
rather than superficial thrombophlebitis.
Infection and thrombophlebitis can appear similar. Pain may
thrombophlebitis?
feature in either condition. Infection as a cause of superficial • Sterile superficial thrombophlebitis—Accounts for most
thrombophlebitis or an alternative diagnosis should be suspected presentations.
if there is evidence of local skin trauma. However, infection
• Traumatic superficial thrombophlebitis—Occurs after limb
usually involves a diffuse area of skin, unlike the localised signs
injury and may be associated with ecchymosis of the
in superficial thrombophlebitis alone. Fever, swelling, and pus
surrounding tissue. Intravenous cannulation and infusions
drainage can be present in 44%, 37%, and 9% respectively of
of irritant products can be causative, including the chemical
patients with infection.6

Correspondence to: J M Scriven mark.scriven@heartofengland.nhs.uk

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BMJ 2015;350:h2039 doi: 10.1136/bmj.h2039 (Published 22 June 2015) Page 2 of 4

PRACTICE

The bottom line


• Superficial thrombophlebitis is usually a benign, self limiting disease, but consideration should be given to specialist referral for duplex
ultrasound imaging and further management
• Patients with limited (below knee) superficial thrombophlebitis without evidence of deep vein thrombosis can be safely managed in
primary care with non-steroidal anti-inflammatory drugs and compression
• Patients with thrombosis near the saphenofemoral or saphenopopliteal junction should be considered for surgical ligation or
anticoagulation
• Surgery should be considered in those with persistent symptoms or evidence of thrombus propagation despite medical treatment

thrombophlebitis produced by sclerotherapy during prothrombin 20210 mutation (10%), and deficiencies in
treatment of varicose veins. antithrombin III, protein C, or protein S (10%).15
• Infective thrombophlebitis—Mostly caused by prolonged
intravenous cannulation causing infection and thrombosis. D-dimer
Appropriate antibiotics should be used for treatment. D-dimer is a fibrin degradation product; its concentration is
• Migratory thrombophlebitis—Recurrent superficial often elevated in deep vein thrombosis and pulmonary embolism
thrombophlebitis at various separate sites without an and may be increased in cases of superficial thrombophlebitis.
identifiable local cause. This can be associated with an As such, it is of little value in differentiating superficial
underlying malignancy, particularly carcinoma of the thrombophlebitis from deep vein thrombosis and does not help
pancreas.11 in diagnosing superficial thrombophlebitis.16

How is it treated?
What are its complications?
The treatment of superficial thrombophlebitis remains variable
• Venous thromboembolism—Superficial thrombophlebitis
and controversial. However, therapeutic strategies must include
may coexist with deep vein thrombosis in 5-53% of
symptomatic relief, limitation of thrombosis extension, and,
patients.12-14 When superficial thrombophlebitis involves
very importantly, reduction of the risk of pulmonary embolism.
veins near the junction with the deep venous system, the
risk of deep vein thrombosis and pulmonary embolism can Currently, there is no single, evidence based therapy.17 A recent
be as high as 18%.12-14 Cochrane review examined a range of treatment modalities
including hosiery, fondaparinux, various formulations of
• Skin hyperpigmentation over the affected vein. heparin, topical and oral non-steroidal anti-inflammatory drugs,
• Infection and abscess formation. and surgery.1 The review concluded that the available evidence
on oral treatments, topical treatment, and surgery was too limited
to inform clinical practice about the effects of these treatments
How is it investigated? on venous thromboembolism or superficial thrombophlebitis
Accepting that superficial thrombophlebitis is a clinical extension. With respect to anticoagulants, the review concluded
diagnosis, it remains important to identify any possible cause that a prophylactic dose of fondaparinux for 45 days seemed to
and determine the extent of thrombosis, its relation to the be a valid therapeutic option.
junctions between superficial and deep venous systems and It is currently accepted in the UK that in cases of limited (below
whether any coexisting deep vein thrombosis is present. knee) superficial thrombophlebitis without evidence of deep
vein thrombosis, compression and non-steroidal
Venous duplex ultrasound scanning anti-inflammatory drugs alone will suffice by providing
Duplex ultrasound is considered the optimal venous imaging symptomatic relief. However, if thrombus extends to the
modality and is recommended to confirm the diagnosis (fig 2⇓), saphenofemoral or saphenopopliteal junctions prophylactic use
exclude deep vein thrombosis, and define disease extent. Clinical of low molecular weight heparin may be indicated. Surgical
examination alone will underestimate the extent of superficial intervention is a controversial option if anticoagulation is
thrombophlebitis in up to 77% of cases.5 Additionally, an contraindicated or not tolerated, but it may compound the risk
associated deep vein thrombosis is reported in 6–53% of cases.8 of venous thromboembolism.
As such, consider all patients with suspected superficial
thrombophlebitis for specialist referral, duplex imaging as Hosiery
necessary, and ongoing management. Graduated compression helps improve venous flow and can
increase local and regional intrinsic fibrinolytic activity. If
Hypercoagulability tolerated, all patients with superficial thrombophlebitis may
In the absence of a local cause, an underlying occult condition benefit from compression stockings with or without adjunctive
may be present. There are no conclusive studies showing a treatments.
causative relationship between hypercoagulable states and
superficial thrombophlebitis. However, there is a relationship Non-steroidal anti-inflammatory drugs
between superficial thrombophlebitis and the prevalence of (NSAIDS)
hypercoagulability. Some argue that, in the absence of an The role of NSAIDs in venous thromboembolic disease is ill
obvious causative factor (such as varicose veins, trauma, cancer), defined, but they are commonly prescribed in the UK to manage
all patients presenting with extensive superficial local symptoms. They reduce extension of superficial
thrombophlebitis should undergo screening for coagulation thrombophlebitis and its recurrence but have no effect on the
anomalies.8 The main coagulation abnormalities associated with incidence of venous thromboembolism.1
superficial thrombophlebitis are factor V Leiden mutation (16%),

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BMJ 2015;350:h2039 doi: 10.1136/bmj.h2039 (Published 22 June 2015) Page 3 of 4

PRACTICE

Anticoagulation Vascular surgeon—During the acute phase response, patients


The most widely used anticoagulants are unfractionated heparin, with thrombus near the junction may be considered for
low molecular weight heparin, and, more recently, fondaparinux. anticoagulation or surgical intervention. Once the acute phase
A randomised controlled trial showed that anticoagulation with has passed then referral is useful to help guide elective
unfractionated heparin, low molecular weight heparin, and superficial venous intervention to reduce the risk of recurrence.
warfarin were all superior to compression therapy alone in Haematologist—All patients with identified coagulation
reducing superficial thrombophlebitis extension.18 More recent abnormality.
studies show that the use of low molecular weight heparin is
superior to unfractionated heparin both in prophylactic and Competing interests: We have read and understood the BMJ policy on
therapeutic doses.19 declaration of interests and have no relevant interests to declare.
Fondaparinux is a newer anticoagulant and has been shown to Provenance and peer review: Commissioned; externally peer reviewed.
significantly reduce the symptoms of superficial
thrombophlebitis, as well as reduce the risk of superficial 1 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the
leg. Cochrane Database Syst Rev 2013;4:CD004982.
thrombophlebitis extension and recurrence when compared with 2 Decousus H, Bertoletti L, Frappe P, et al. Recent findings in the epidemiology, diagnosis
placebo.1 20 To date, there are no reliable data comparing and treatment of superficial-vein thrombosis. Thrombosis Res 2011;127(suppl 3):S81-5.
3 Rosendaal FR. Thrombosis in the young: epidemiology and risk factors. A focus on venous
fondaparinux with low molecular weight heparin. The absence thrombosis. Thromb Haemost 1997;78:1-6.
of evidence prevents firm recommendations regarding the 4 Decousus H, Quere I, Presles E, et al. Superficial venous thrombosis and venous
thromboembolism: a large, prospective epidemiologic study. Ann Intern Med
duration of treatment and the long term efficacy of 2010;152:218-24.
anticoagulation in patients with isolated superficial 5 Markovic MD, Lotina SI, Davidovic LB, et al. [Acute superficial thrombophlebitis--modern

thrombophlebitis.1 6
diagnosis and therapy]. Srpski arhiv za celokupno lekarstvo 1997;125:261-6.
Baker CC, Petersen SR, Sheldon GF. Septic phlebitis: a neglected disease. Am J Surg
1979;138:97-103.

Antibiotics 7 De Maeseneer MGR. Superficial thrombophlebitis of the lower limb: practical


recommendations for diagnosis and treatment. Acta Chir Belg 2005;105:145-7.
Antibiotics have no role in the treatment of thrombophlebitis, 8 Leon L, Giannoukas AD, Dodd D, et al. Clinical significance of superficial vein thrombosis.
Eur J Vasc Endovasc Surg 2005;29:10-17.
except in clear cases of infection. 9 Lofgren EP, Lofgren KA. The surgical treatment of superficial thrombophlebitis. Surgery
1981;90:49-54.
10 National Institute for Health and Care Excellence. Varicose veins in the legs. the diagnosis
Surgical intervention and management of varicose veins. (Clinical guideline 168.) 2013. https://www.nice.org.
uk/guidance/cg168.
Whether surgery offers any benefit over pharmacological therapy 11 Diaconu C, Mateescu D, Balaceanu A, et al. Pancreatic cancer presenting with
for initial treatment remains controversial, and it should probably paraneoplastic thrombophlebitis—case report. J Med Life 2010;3:96-9.
12 Lutter KS, Kerr TM, Roedersheimer LR,et al. Superficial thrombophlebitis diagnosed by
be limited to the small number of cases where superficial duplex scanning. Surgery 1991;110:42-6.
thrombophlebitis propagates towards the saphenous junctions 13 Chengelis DL, Bendick PJ, Glover JL,et al. Progression of superficial venous thrombosis
to deep vein thrombosis. J Vasc Surg 1996;24:745-9.
despite effective medical therapy. Surgical saphenous ligation 14 Bergqvist D, Jaroszewski H. Deep vein thrombosis in patients with superficial
with compression is superior to compression alone in preventing thrombophlebitis of the leg. BMJ 1986;292:658-9.

superficial thrombophlebitis propagation and thromboembolism. 15 Martinelli I, Cattaneo M, Taioli E, et al. Genetic risk factors for superficial vein thrombosis.
Thromb Haemost 1999;82:1215-7.
However, surgery is itself associated with venous 16 Gillet JL, Ffrench P, Hanss M, et al. [predictive value of d-dimer assay in superficial
thromboembolism. The evidence is still lacking for a comparison thrombophlebitis of the lower limbs]. J Malad Vasc 2007;32:90-5.
17 Dua A, Patel B, Heller J, et al. Variability in the management of superficial venous
of surgery and anticoagulants. thrombophlebitis among phlebologists and vascular surgeons. Perspect Vasc Surg
Endovasc Ther 2013;25:5-10.
With respect to recurrence of superficial thrombophlebitis, one 18 Belcaro G, Nicolaides AN, Errichi BM, et al. Superficial thrombophlebitis of the legs: a
small randomised trial suggests that saphenofemoral randomized, controlled, follow-up study. Angiology 1999;50:523-9.

disconnection is superior to LMWH in reducing the risk of 19 Wichers IM, Di Nisio M, Buller HR,et al. Treatment of superficial vein thrombosis to prevent
deep vein thrombosis and pulmonary embolism: a systematic review. Haematologica
recurrence (3.3% v 10%), but with higher risk of 2005;90:672-7.
thromboembolism,21 though it is not possible to draw firm 20 Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial
vein thrombosis in the legs. N Engl J Med 2010;363:1222-32.
conclusions from this small study. 21 Lozano FS, Almazan A. Low-molecular-weight heparin versus saphenofemoral
disconnection for the treatment of above-knee greater saphenous thrombophlebitis: a
prospective study. Vasc Endovasc Surg 2003;37:415-20.
When to refer
Consider referring patients with suspected superficial Cite this as: BMJ 2015;350:h2039
thrombophlebitis for venous duplex scanning, which can then © BMJ Publishing Group Ltd 2015

guide treatment and the need for further specialist intervention.10

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BMJ 2015;350:h2039 doi: 10.1136/bmj.h2039 (Published 22 June 2015) Page 4 of 4

PRACTICE

Figures

Fig 1 Typical superficial thrombophlebitis within a calf varicosity. Note the brown haemosiderin discoloration and lumpiness

Fig 2 Typical duplex ultrasound appearance of superficial phlebitis involving a varicosity arising from the great saphenous
vein (GSV). Note the echogenic material within the varicose vein

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