Practice: Superficial Thrombophlebitis (Superficial Venous Thrombosis)
Practice: Superficial Thrombophlebitis (Superficial Venous Thrombosis)
Practice: Superficial Thrombophlebitis (Superficial Venous Thrombosis)
Practice
PRACTICE
PRACTICE POINTER
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2039 doi: 10.1136/bmj.h2039 (Published 22 June 2015) Page 2 of 4
PRACTICE
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%),
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2039 doi: 10.1136/bmj.h2039 (Published 22 June 2015) Page 3 of 4
PRACTICE
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.
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
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
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
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe