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COAGULATION UPDATE Issue #3 2012 COAGULATION UPDATE Issue #3 2012 SUPERFICIAL THROMBOPHLEBITIS Irina Chibisov, MD, Hemostasis and Thrombosis Clinic ITxM Diagnostics, Assistant Professor of Pathology, University of Pittsburgh Medical Center ___________________ _______________________________ INTRODUCTION THROMBOPHLEBITIS AS THE RESULT OF AN Superficial thrombophlebitis is an inflammatory reaction INFECTION with thrombus. It usually is a benign, self-limiting Septic phlebitis usually occurs in association with the disease, but can be recurrent and persistent. When long-term use of an intravenous cannula inserted for the affecting the greater saphenous vein, thrombophlebitis administration of fluid or medications. can progress into the deep venous system, leading to pulmonary embolism. Although superficial Aerobic and anaerobic as well as mixed infections have thrombophlebitis generally occurs in the lower been related to superficial venous thrombosis. extremities, it can happen anywhere a medical intervention takes place, such as in the arm or neck (eg. MIGRATORY THROMBOPHLEBITIS external jugular vein) from intravenous catheters. Migratory thrombophlebitis is characterized by RISK FACTORS recurrent episodes of thrombosis developing in superficial veins at varying sites in the limbs and trunk, Risk factors for developing superficial thrombophlebitis but most commonly in the lower extremity. are similar to those of DVT. The most common one tends to be varicose veins in the lower extremity; others The association of carcinoma was first reported by include advancing age (≥60 years), female gender, Trousseau in 1856. Migratory thrombophlebitis especially obesity, pregnancy, recent surgery or immobilization, prevalent with carcinoma of the pancreas. hormonal influences, smoking, IV lines and drugs, history of prior venous thromboembolism (VTE), and Phlebitis occurs in diseases associated with vasculitis, hypercoagulable states, including malignancy. such as polyarteritis nodosa and Buerger disease. Types of superficial venous thrombosis: In each type of superficial thrombophlebitis, the TRAUMATIC THROMBOPHLEBITIS condition presents as redness and tenderness along the Superficial venous thrombosis following an injury course of the vein, usually accompanied by swelling. usually occurs in an extremity. Bleeding also can occur at the site of a varicose vein. Superficial thrombophlebitis of the upper extremities Thrombophlebitis frequently occurs at the site of an usually occurs at infusion sites or sites of trauma. intravenous infusion and is the result of irritating drugs, Superficial thrombophlebitis can occur in the external or the intraluminal catheter. This is the most common jugular vein if it has been used for an infusion site. type of thrombophlebitis. It may take months to Superficial thrombophlebitis may take months to completely resolve. completely resolve. Iatrogenic (chemical) phlebitis may be deliberately LABORATORY STUDIES produced by sclerotherapy for varicose veins. Patients who present with spontaneous thrombophlebitis THROMBOPHLEBITIS IN A VARICOSE VEIN without a previous indwelling intravenous catheter or Superficial thrombophlebitis frequently occurs in other precipitating cause should be considered for varicose veins. Superficial thrombophlebitis along the evaluation for a hypercoagulable state. course of the greater saphenous vein is more often Patients with a past history of another thromboembolic progresses to the deep system. event should undergo a workup. Evaluation should include tests for factor V Leiden and prothrombin gene mutations, protein C, protein S and antithrombin III deficiencies, lupus anticoagulant with anticardiolipin and incidence of progression to deep venous thrombosis has beta 2 glycoprotein I antibodies. High factor VIII been reported. concentration has also been reported to be an If the thrombophlebitis is associated with a cannula or independent risk factor for recurrent superficial a catheter, the device should be removed. thrombosis. The risk of complications with acute superficial Migratory thrombophlebitis, especially without good thrombosis have led many investigators to favor cause, may be an indication for a more detailed systemic anticoagulation when the thrombus evaluation including search for malignancy. This may approximates the saphenous junctions and when more include serum carcinoembryonic antigen (CEA), than 5 cm of the saphenous trunk is involved, as shown prostate-specific antigen (PSA), colonoscopy, CT scans, by duplex ultrasonography. and mammography. The 2012 American College of Chest Physicians IMAGING STUDIES guidelines recommend the use of a prophylactic dose of fondaparinux or LMWH for 45 days over no Duplex ultrasound evaluation is the diagnostic study of anticoagulation in patients with lower extremity choice to search for venous thrombosis. The most superficial thrombosis of at least 5 cm in length. diagnostic finding is a lack of compressibility of the vein. Thrombosis isolated to superficial varicosities may be A key question concerns the location and extent of managed more conservatively by avoiding superficial thrombosis, as well as the proximity to the anticoagulation in favor of anti-inflammatory agents. deep venous system at the saphenofemoral or saphenopopliteal junction. CONCLUSION Venography is rarely required. It should be usually Superficial vein thrombosis is more than a benign avoided because of the potential complications of disease process. If may result in pulmonary embolism or intravenous contrast administration, which can itself lead VTE complications. Diagnostic imaging is important in to phlebitis. determining the best course of action, and referral to a After an initial diagnosis of superficial vein specialist may be warranted. Ambulation, thrombophlebitis, a follow-up duplex ultrasound compression therapy, anticoagulant and anti- examination should be performed to look for progression inflammatory agents make up the current standard of of disease after treatment is initiated. care, and choice depends on thrombus burden. Although TREATMENT large randomized trials are lacking, epidemiologic studies documenting the prevalence of DVT or pulmonary Practice guidelines exist for patients with complications embolism in patients with superficial phlebitis may of VTE, but data is generally lacking for superficial warrant more aggressive medical therapy. thrombophlebitis of the lower extremity. The primary goal of management is to prevent thrombus extension and risk of VTE. All other therapy is directed at patient REFERENCES comfort. The treatment of superficial venous thrombosis 1. Dewar C, Panpher S. Incidence of deep vein thrombosis in depends on its etiology, extent, and symptoms. Duplex patients diagnosed with superficial thrombophlebitis after scanning gives evaluation of the extent of disease and presenting to an emergency department outpatient deep vein thus allows determining more rational therapy. thrombosis service. Emerg Med J 2010;27(10):758-761. 2. Decousus H, Epinat M, Guillot K, et al. Superficial vein For the superficial, localized, mildly tender area of thrombosis: risk factors, diagnosis, and treatment. Curr Opin thrombophlebitis that occurs in a varicose vein, Pulm Med 2003;9(5):393-397. treatment with mild analgesics, such as aspirin or 3. Decousus H, Quéré I, Presles E, et al. Superficial venous NSAID, and the use of elastic support usually are thrombosis and venous thromboembolism. Ann Intern Med 2010;152(4):218-224. sufficient. Patients are encouraged to continue their 4. Kearon C, Kahn S, Agnelli, et al. Antithrombotic therapy for usual daily activities. venous thromboembolic disease: American College of Chest If extensive varicosities are present or if symptoms Physicians evidence based clinical practice guidelines (8th persist, phlebectomy of the involved segment may be Edition). Chest 2008;133(6 Suppl):454S-545S. indicated. More severe thrombophlebitis should be treated by For any questions or follow-up information, please bed rest with elevation of the extremity and the contact: Irina Chibisov, MD at [email protected] or application of hot, wet compresses. Elastic stockings or 412-209-7350. ACE bandages are indicated when the patient becomes ambulatory. Patients who present with thrombosis of the saphenous veins should be considered for anticoagulation or ligation of the saphenous vein. A high.
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