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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3786_Библиотеки_им_академика_М_И_Перельмана
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Superfi cial Venous
https://t.me/med1917
Thrombophlebitis
Marlin W. Schul
1 9
Contents
19.1 Introduction ................................................ 259
19.2 Clinical Features ........................................ 261
19.3 Epidemiology/Pathophysiology ................. 262
19.4 Risk Factors for STP.................................. 262
19.5 Risk for VTE Complications/
Recurrence .................................................. 263
19.6 Deep Vein Thrombosis ............................... 264
19.7 Pulmonary Embolus .................................. 264
19.8 Diagnostic Approach ................................. 266
19.8.1 Duplex Ultrasonography .............................. 266
19.8.2 Acute Phase Testing ..................................... 266
19.8.3 Follow-Up Duplex Scanning ........................ 266
19.8.4 Laboratory Testing ....................................... 269
19.9 Treatment Options ..................................... 271
19.9.1 Ambulation Versus Bed Rest ....................... 271
19.9.2 Compression Therapy .................................. 271
19.9.3 Pharmacotherapy .......................................... 271
19.9.4 Surgical Intervention .................................... 272
19.10 Management Strategies ............................. 274
19.10.1 Superfi cial Thrombophlebitis
Isolated to Tributaries .................................. 275
19.10.2 Superfi cial Thrombophlebitis with
Saphenous Vein Involvement in the
Presence of Varicose Veins .......................... 275
19.10.3 Superfi cial Thrombophlebitis with VTE
Complications at Presentation/STP
Without Varicose Veins ................................ 275
19.10.4 Unusual Sites of Superfi cial
Thrombophlebitis ......................................... 275
19.11 Conclusion/Summary ................................ 276
References ................................................................. 278
Abstract
Superfi cial thrombophlebitis offers an array of
presentations. Yet despite the knowledge that
has emerged over the past 20 years, the curricula in medical schools and residencies fail to
acknowledge STP as anything more than a selflimiting disease. The gap in venous education
in the USA leads many unknowing providers
to prescribe a recipe for thrombus extension,
based upon established yet inaccurate dogma
associated with STP. Although clinical trials are
emerging, there is far more to be learned about
this topic. This chapter discusses the latest in
peer- reviewed literature, enabling the reader
to optimize outcomes through minimizing the
risk of complications related to this common
venous condition of the lower extremity.
19.1 Introduction
M. W. Schul , MD, MBA, RVT, FACPh
Venous and Lymphatic Medicine,
Lafayette Regional Vein and Laser Center,
A division of Unity Healthcare, LLC , Lafayette , IN , USA
e-mail: mschul@lafayetteveincenter.com
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_19, © Springer International Publishing Switzerland 2014
Evidence pertaining to the diagnosis and management of superfi cial thrombophlebitis (STP) is
controversial and poorly understood. This condition is common, yet largely minimized when
compared to its big brother, deep vein thrombosis
(DVT) [
1 ]. Existing data suggests this venous
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condition is more than a trivial concern, yet
despite what we know, debate remains on best
management strategies [ 2 , 3 ]. Frequent reports of
concomitant deep vein thrombosis with or without pulmonary embolus, align the pathophysiology of STP more closely with DVT [ 1 , 2 ].
Anatomically, this chapter addresses superfi cial thrombosis above the level of the muscular
fascia, including phlebitis involving saphenous
trunks and tributaries (Fig. 19.1 ). The abbrevia-
tion of STP will be utilized throughout the chapter to distinguish this entity from the common
cardiac arrhythmia. Discussion of post-ablation
superfi cial thrombosis, both thermal and chemical, is reserved for other sections of this text.
Superfi cial thrombophlebitis offers an array
of presentations. Yet despite the knowledge that
has emerged over the past 20 years, the curricula in medical schools and residencies fail
to acknowledge STP as anything more than a
self-limiting disease. The gap in venous education in the USA leads many unknowing providers to prescribe a recipe for thrombus extension,
based upon established yet inaccurate dogma
associated with STP. Although clinical trials are
emerging, there is far more to be learned about
this topic. Mass adoption of present management
principles is not likely to occur overnight. The
case presentations shared in this chapter will arm
providers with the latest in peer-reviewed literature, enabling the reader to optimize outcomes
Fig. 19.1 Infl amed bulbous varices above and below the
knee with an acute bout of STP
through minimizing the risk of complications
related to this common venous condition of the
lower extremity.
Case 1. JJ
JJ is a 35-year-old Caucasian male with chief
complaint of leg pain, aching, and heaviness for
2 weeks. He reports sudden onset of symptoms
with “fi rm knots” over the medial and anterior
thigh. JJ has suffered from symptomatic vari-
cosities over the past 5 years. At the time of
presentation, no therapy had been instituted.
There is no past medical history except for
the presence of varicosities. He takes no medicines and shares no drug allergies. Family
history is negative for varicose veins, venous
ulcers, or “blood clots.” JJ is a business owner
of a sports bar and limousine service and
works long hours standing or sitting. He does
not drink or smoke. Review of systems reveals
no further concerns.
Vital signs as follows: Respiratory rate 12,
heart rate 82, blood pressure 131/76, oxygen
saturation 99 %, and a body mass index (BMI)
of 40.4. Physical exam was unremarkable with
the exception of left lower extremity cluster
of veins with overlying erythema and proximal streaking (Fig. 19.2 ). No palpable cord is
appreciated through the girth of the affected
extremity.
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Fig. 19.2 Case #1
– JJ’s physical
fi ndings. A dramatic
infl ammatory response
is seen corresponding
to painful thrombosed
superfi cial varices
261
Given JJ’s history and physical fi ndings:
Does this patient have the working diagnosis of STP?
What are the clinical features of STP?
19.2 Clinical Features
Superfi cial thrombophlebitis offers a spectrum of
presentations, yet the most common is that of
sudden onset of leg discomfort with fi rm,
infl amed varicosities. A palpable cord may be
present with saphenous or deep venous involvement [ 1 ]. Fluctuance is frequently noted over the
varicosities involved, and edema may be present.
Infl ammation over the region may at times be
extreme despite the lack of a true infectious etiology [ 2 ]. In patients with severe and sustained
infl ammatory response in a superfi cial varix,
hemorrhage may occur and thrombus may be
expelled as the skin weakens [ 3 ]. As Sobreira
et al. reported, the proximal most point of thrombus extends, on average, 15 cm beyond where
clinically evident, rendering the physical exam a
limited tool [ 4 ].
The infl ammatory process that is commonly
linear, forces us to consider other potential
pathology and a broader differential diagnosis
What is the differential diagnosis of STP?
Does this patient have risk factors for DVT?
What tests are indicated at the initial evaluation of clinically suspected STP?
Table 19.1 Differential diagnosis considerations for
STP
Posttraumatic – hematomas adjacent to veins
Venipuncture
Intravenous drug abuse
Allergic reaction to insect bites
Filarial infestation
Lymphangitis
Cellulitis
Erythema nodosum
Erysipelas
Alternative considerations for patients presenting with red
streaks and suspicion for superfi cial thrombophlebitis
(Table 19.1 ). Historical features of exotic travel,
intravenous drug abuse, recent hospitalization
with intravenous catheter, insect bites, etc., offer
added insight to the potential underlying pathology. The lower extremities are the most commonly involved site, yet STP may occur in
superfi cial veins throughout the body, including
upper extremity, breast, and genital veins [ 5 – 8 ].
Although the diagnosis of STP is typically not in
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question, the true extent and nature of thrombus
burden must be verifi ed.
19.3 Epidemiology/
Pathophysiology
The Tecumseh Community Health Study was the
fi rst large-scale effort to defi ne the incidence of
venous thromboembolic phenomena including
superfi cial thrombophlebitis. Combining sequential history and physical exams, Coon et al. estimated the STP incidence between 3 and 11 % of
the population [ 5 ]. At the time of the Tecumseh
study, it was estimated that 123,000 cases occur
each year [ 6 ]. The true prevalence is likely much
higher. As duplex ultrasonography has emerged,
we have learned much more about patterns of
STP and complications associated with this disease state.
Nothing has been more important in understanding the patterns and clinical sequelae of
superfi cial thrombophlebitis than the development of duplex ultrasound technology. In
Lutter’s series of nearly 13,000 lower extremity
duplex evaluations for deep vein thrombosis,
1,412 were found to have acute venous thrombosis. Of these, one of every eight was found to
involve superfi cial venous system. The location
of thrombus most commonly involved the great
saphenous vein (GSV) (69 %), followed by the
small saphenous vein (30 %), and isolated to
varicose veins (13 %) [ 7 ]. Multi-segment
involvement is commonly seen as is bilateral
involvement (9 %) (Fig. 19.3 ).
The pathophysiology of STP is thought to be
similar to deep vein thrombosis, except STP is
clearly associated with varicose veins as the predominant pattern [ 9 ]. Histopathology has been
suggested to differ with regard to the extent of
infl ammation involving the vein wall, where STP
involves a tremendous amount of infl ammation
compared to that found with acute deep vein
thrombosis [ 8 ]. As shown in Fig. 19.4 , extensive
infl ammatory changes are noted throughout the
vein wall in a patient with phlebitis isolated to the
superfi cial vessels. Over time the region of thrombus may become more organized and incorporated
Fig. 19.3 Bilateral STP Image. This image depicts bilat-
eral STP involving varices below the knee on the right leg
and the left anterior thigh
into the vein wall, may become completely recanalized, or may remain scarred with venous septae
in an otherwise refl uxing vessel [ 10 ] (Fig. 19.5 ).
19.4 Risk Factors for STP
When considering risks for the development of
STP, one must refl ect on Virchow’s triad including venous stasis (immobilization or refl ux), vessel injury or trauma, and thrombophilia states
due to hereditary or acquired conditions. The
risks for developing superfi cial thrombophlebitis have been gleaned from numerous studies,
many of which, not surprisingly, are well aligned
with those of deep vein thrombosis (Table 19.2 ).
The most common predisposing risk includes
varicose veins in the lower extremity, occurring
in 61–93 %, advancing age ≥60, female/male
ratio of 2:1, obesity in 20 %, multiparity, recent
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Fig. 19.4 Histopathology
seen in acute STP, Case #1.
Black arrow indicates
thrombus within the vein
lumen. White arrow
indicates the transmural
infl ammation and neutrophil
infi ltration
Fig. 19.5 Residual scar
from STP in lumen of the
great saphenous vein
263
Table 19.2 Common risk factors for STP and DVT
Shared risk factors for STP or DVT
Varicose veins
Previous DVT/STP
Immobilization
Malignancy
Trauma
OCP/puerperium
Hypercoagulable states
surgery/immobilization, hormonal infl uences,
history of prior venous thromboembolism
(VTE), and hypercoagulable states including
malignancy [ 9 , 11 ]. Seasonal variations have also
been reported where a peak incidence is seen in
warmer summer months [ 11 ].
19.5 Risk for VTE Complications/
Recurrence
Superfi cial thrombophlebitis and the association
with complications of DVT, with or without pulmonary embolus, have been noted for 7 years.
Once thought to be a rare fi nding, duplex ultrasonography reports have revealed concomitant
deep and superfi cial vein thrombosis at a rate of
8.6–24 % [ 9 , 12 – 14 ] This confi rms a reality that
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Fig. 19.6 STP at the saphenopopliteal junction with free-fl oating tongue
the clinical picture of superfi cial thrombophlebitis
may, and often, harbors more serious sequelae
than previously suspected.
There are two patient populations at the
time of initial presentation, one of isolated STP
and another with complications of concomitant DVT or pulmonary embolus. Identifying
which patients possess the greatest propensity in
developing VTE complications is of paramount
importance.
19.6 Deep Vein Thrombosis
Anatomic location of the thrombus (e.g., near
the saphenofemoral or saphenopopliteal junctions) has not been proven to yield a higher proclivity for VTE events. Lutter’s study compared
populations with isolated STP to those with
combined disease at initial presentation and
found age >60, prior history of DVT, recent
immobilization, and systemic infection as statistically signifi cant risk factors for developing
concomitant DVT and STP (Fig. 19.6 ). Quenet
identifi ed 427 consecutive hospitalized patients
with isolated STP. Over the following 3 months,
4.1 % (17/413) were confi rmed to have developed deep vein thrombosis. Univariate and multivariate regression analysis revealed male sex,
history of VTE, severe chronic venous insuffi ciency, and sudden onset of STP as statistically
signifi cant risk factors for developing VTE complications [ 4 ].
19.7 Pulmonary Embolus
The life-threatening complication of pulmonary
embolus (PE) has been largely thought to occur
only in the presence of deep vein thrombosis.
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STP as a suspected cause of pulmonary embolus
was fi rst described by Richter in 1905 [ 9 ]. Is it
possible that isolated superfi cial thrombophlebitis may in fact cause pulmonary embolus?
Verlato et al. prospectively studied 21 consecutive patients with isolated STP involving the
proximal great saphenous vein. Each subject
received systemic duplex scanning excluding
presence of DVT through the calf veins and
underwent chest radiography and pulmonary
perfusion scanning. Surprisingly, despite general lack of symptomatology for pulmonary
embolus, one-third was found to have high
probability scintigraphy studies [ 12 ]. Sobreira
et al. studied 60 consecutive patients with clinical fi ndings of STP. Each subject received complete duplex scanning of the lower extremities
Case 2. JD (Fig. 19.7 )
JD is a 70-year-old Caucasian male presenting
with “knots” in the left calf after a 16 h car ride
from coastal North Carolina to Chicago. He sat
in the back seat of a car with confi ned space for
leg room. He reported to an urgent care facil-
ity who made a diagnosis of STP, and he was
referred for fi tted gradient compression.
Past medical history is signifi cant for
degenerative joint disease, hypertension,
hypercholesterolemia, and type II diabetes
mellitus. He has no prior history of thrombosis yet has had varicose veins in the calf that
have not previously been problematic. Family
history is negative for varicose veins, venous
ulcers, or “blood clots.” JD does not drink or
smoke. He enjoys golf and church activities.
Review of systems was noncontributory.
JD has normal vital signs, oxygen saturation of 98 %, and a BMI of 29.0. He communicates easily and appears in no distress.
Physical fi ndings reveal a fi rm, tender, infl ammatory region in the medial proximal calf,
corresponding to an intersaphenous branch.
A pink hue is present over the fi rm varicosities. Trace edema is noted at the ankle in addition to high-pressure telangiectasia.
and pulmonary perfusion scanning. Although
13 (21.7 %) patients were found to have concomitant DVT at presentation, 17 (28 %) were
found to have high probability scans. Five of the
17 (29 %) found to have pulmonary embolus
had concomitant DVT [ 10 ].
Although large randomized trials are lacking,
the simultaneous occurrence of superfi cial and
deep vein thrombosis suggests that this is more
than a benign disease process [ 13 , 14 ].
Epidemiology studies declaring the relatively
high incidence of concomitant DVT and/or PE
among STP patients warrant further consideration toward the prevention of further thromboembolic events. If merely 1 % of these cases
result in PE or VTE complications, thousands of
lives are placed at risk [ 15 ].
Fig. 19.7 Case #2 – JD’s calf image. This patient demon-
strates painful bulbous varices of the calf with a faint pink
hue after long car ride in a confi ned space
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The urgent care advised the use of an
anti- infl ammatory reported that an antibiotic may be required if there was no
improvement. No laboratory tests or imaging tests performed at the time of his initial
evaluation.
What risk factors does JD possess that
place him at risk for developing STP?
19.8 Diagnostic Approach
Superfi cial thrombophlebitis most often occurs in
patients with varicose veins but may also occur in
normal saphenous veins in patients with an
underlying thrombophilia. Given the common
fi ndings of DVT and/or pulmonary embolus in
patients with superfi cial thrombophlebitis, once
the clinical assumption is made, affi rmation
requires further diagnostic testing.
19.8.1 Duplex Ultrasonography
The prevalence of concomitant venous complications in patients with superfi cial thrombophlebitis
mandate duplex ultrasound for each patient suspected of this condition [ 13 , 14 ]. Duplex evalu-
ation is valued for proving the diagnosis of STP
while accurately assessing the thrombus burden
throughout the lower extremity. The results of the
duplex study serve to not only declare the presence or absence of thrombus but aid in identifying
presence of complications found commonly in
patients with STP. Simply put, duplex ultrasonography is the most critical of studies to perform and
may indicate a need for more advanced imaging.
19.8.2 Acute Phase Testing
Principles of assessing a lower extremity for
thrombosis are well documented. Systematic
comprehensive whole-leg assessment of venous
anatomy be mapped and for thrombus burden and
What risk factors does JD possess that
place him at risk for VTE?
Describe a practical approach to evaluate
JD and guide his treatment.
Do you agree with the urgent care recommendations of anti-infl ammatory agents,
an antibiotic, and compression therapy?
Please explain.
the extent of venous refl ux [ 13 ]. Bilateral scan-
ning is indicated when bilateral symptoms are
present and when institutional protocols mandate
the study. Complete testing of an asymptomatic
contralateral limb is debatable beyond assessing
the most proximal segments of the limb [ 14 ].
As seen in an acute setting, probe compression
in the region of thrombosis reveals noncompressible vessels which are hypoechoic (Fig. 19.8 ).
The standard commonly used in clinical studies
to defi ne thrombus in the great or small saphenous vein includes a segment at least 5 cm in
length (Fig. 19.9 ). A free-fl oating thrombus tip
may be seen as an extensive STP protrudes into
the lumen of the common femoral or popliteal
vein (Fig. 19.10a, b ). Valsalva testing and spec-
tral waveform patterns are helpful in assessing
presence of proximal obstruction (Fig. 19.11 ).
Duplex fi ndings or signs of proximal involvement should trigger algorithms to address pelvic
vein pathology and the central circulation.
19.8.3 Follow-Up Duplex Scanning
Although there may be institutional standards,
there are generally no accepted principles for
serial duplex scans in this patient population
[ 16 ]. Despite the argument regarding cost effec-
tiveness, periodic surveillance of thrombus burden is strongly recommended for patients at
higher risk for thrombus extension (e.g., involving proximity of the saphenous junctions or proximal one-third of the great saphenous vein) [ 4 ]. If
the patient is not a candidate for anticoagulation,
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Fig. 19.8 STP of the GSV. Probe compression reveals limited compression of the great saphenous vein of the proximal
thigh
Fig. 19.9 STP and
thrombus tip in mid-thigh in
a nondilated saphenous vein
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Fig. 19.10 STP at the
saphenofemoral junction
(duplex and standing photo
of limb). ( a ) This image
depicts the thrombus
extending from the GSV
through the SFJ and into the
CFV for the patient below.
( b ) This image demonstrates
limited fi ndings with focal
tenderness at the knee
M.W. Schul
a
b
sequential scanning is imperative. As the
majority of thrombus extends during the fi rst
week, a general rule of thumb is to reimage
patients within 2–10 days [ 17 , 18 ]. Additional
studies are recommended for increasing pain or
swelling of the affected limb and near the anticipated end of anticoagulation. This permits not
only an assessment of residual thrombus burden
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