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19 Sup erfi cial Venous Thrombophlebitis
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Fig. 19.11 CFV with STP extension with and without Valsalva
but insight to residual refl ux and permits a provider to determine the best surgical course of
action if indicated.
developing STP [ 20 ]. Recently, MTHFR C677T
polymorphism was found to be signifi cantly
higher in patients with superfi cial thrombophlebitis when compared to patients with DVT [
Despite the reality that an underlying thrombo-
19.8.4 Laboratory Testing
philic state may exist in a substantial percentage
of patients with STP, acute phase laboratory
Patients with their fi rst bout of superfi cial
thrombophlebitis may indeed be manifesting
their fi rst event of an as of yet unknown thrombophilia [ 17 ]. The incidence of hypercoagulable
conditions has been as high as 35 % in a series
reported by Hanson et al . [ 19 ]. Schonauer pro-
spectively observed 615 patients with fi rst VTE
who had completed 3 months anticoagulation
therapy. Over an average of two and one-half
years, 45 (7.3 %) STP events were reported.
When analyzed, elevated factor VIII levels
proved to be an independent risk factor for
testing is best geared toward those commonly
performed prior to initiating anticoagulation. In
these patients, a complete blood count with differential and platelets, PT/aPTT, and D-dimer
generally suffi ce in the acute phase. Given the
features of assessing a patient for inherited
thrombophilia, it is not only timing of testing
that is important, but rather an assessment
whether the fi ndings may change the course of
management [ 21 ]. A thorough review of throm-
bophilia and testing may be found in the chapter
dedicated to this topic.
21 ].
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M.W. Schul
Case 3. JA (Fig. 19.12 )
JA is a 38-year-old Caucasian male presenting with chief complaint of “fi rm painful knot” over the right anterior thigh for
1 week. The discomfort is constant and
associated with red streaking along the
inner thigh and superfi cial vessels of the
anterior thigh and leg. There are no aggravating or relieving factors and no therapy
had been instituted. Past medical history is
signifi cant for apparent uncomplicated STP
3 years prior, and a remote right ankle injury
without loss of function. Family history is
negative for “blood clots” or known thrombophilia, yet positive for varicose veins and
severe venous insuffi ciency. JA is married,
he is a nonsmoker. He is a successful farm
equipment salesman, spending long hours
on the road. Review of systems revealed a
1 week history of nonproductive cough and
dyspnea.
Vital signs reveal a respiratory rate of 20,
heart rate of 72, a blood pressure of 128/70,
and oxygen saturation of 98 %. JA is morbidly
obese in no apparent distress. Physical exam
was unremarkable with the exception of an
extensive superfi cial thrombophlebitis with
fi rm, painful varices with overlying infl ammation above and below the knee. A palpable
cord was easily noted along the medial thigh
from just below the knee to the proximal thigh.
Pretibial edema is noted, and pulses are equal
bilaterally.
Duplex study revealed a normal deep system from calf veins through the common femoral vein without signs of proximal obstruction.
Fig. 19.12 Case #3 – JA SFJ with and without compression
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Superfi cial thrombosis was noted in the GSV
from just below the knee proximally to the
superfi cial epigastric vein (Fig.
Tributaries in the thigh and leg were involved
in the thrombotic process and contiguous
with the GSV. A thrombosed intersaphenous
vein coursed to the popliteal fossa, joining the
small saphenous vein near the saphenopopliteal junction (SPJ). The thrombus extended
to the SPJ yet the small saphenous was com-
19.12 ).
19.9 Treatment Options
Controversies surrounding management of
superfi cial thrombophlebitis are abundant. Best
practice guidelines exist for patients with STP
and complications of VTE, but data is lacking for
all other categories. Existing treatment options
are reviewed further on, sharing existing evidence as it pertains to preventing VTE complications in patients with STP.
19.9.1 Ambulation Versus Bed Rest
Many reference texts in vascular surgery and
primary care continue to tout bed rest as part
of the mainstay of therapy for STP and DVT.
Ambulation alone is not suspected to be the
sole means to prevent VTE, yet an effective calf
pump will effectively reduce venous stasis. The
recommendation for bed rest in patients with
acute thrombosis is a simply recipe for thrombus
extension and potential complications [ 15 ]. In a
randomized study by Partsch, compression and
walking were shown superior to bed rest and elevation in reducing edema, reducing the amount
of discomfort, and in minimizing thrombus
extension in patients with proximal DVT [ 22 ].
Although we may not extrapolate the value of
ambulation to encompass all thrombotic events
of the lower extremity, one cannot dismiss the
potential benefi t.
pressible and without refl ux in the distal
two-thirds.
What is the likelihood that JA has already
passed pulmonary emboli to explain his
dyspnea?
What risk factors suggest JA is at higher
risk of developing VTE complications?
Are any further diagnostic tests indicated?
What management strategies would you
consider?
19.9.2 Compression Therapy
There should be little argument that compression
offers the most scientifi c benefi t for this condition.
Established benefi ts include symptomatic relief
as well as prophylaxis against the development of
DVT [ 18 ]. In a recent multicenter epidemiologic
study involving 844 patients with STP, 99.7 %
were prescribed elastic compression stockings or
compression bandages until they could be seen
by a vascular specialist [ 18 ]. Given the series
of Decousus studies, we may easily report that
compression therapy using gradient compression stockings or leg wraps is recommended for
patients with superfi cial thrombophlebitis.
19.9.3 Pharmacotherapy
19.9.3.1 Anticoagulation
Whether to employ systemic anticoagulation
is dependent upon the burden of thrombus, or
geographic standards of care. The management
of uncomplicated deep vein thrombosis and pulmonary embolus are clear, while the management of STP continues to evolve, incorporating
low-molecular- weight heparin, warfarin, and
fondaparinux [ 23 , 24 ]. The prevalence of comor-
bid pathology and risk of complications with
acute superfi cial thrombosis have led many investigators to favor systemic anticoagulation when
the thrombus is near the saphenous junctions
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Table 19.3 Summary of current guidelines for duration of anticoagulation
Disease state Compression Anticoag NSAIDs Ambulation I and D Antibiotics Surgery
Isolated tributaries ++ − + ++ +++ − −
Saphenous involvement
and VVs
Combined STP and DVT,
STP without VVs
Septic thrombophlebitis ++ +/− − ++ + +++ +++++
++ +45 days − ++ ++ − −
++ +3 months − ++ − − −
M.W. Schul
or over 5 cm of the saphenous trunk in length.
Systemic reviews by Wichers et al. demonstrated
anticoagulation using low-molecular- weight
heparin (LMWH) was benefi cial in reducing the
risk of thrombosis extension in the near term
but failed to provide reduction in VTE events
during the longer-term follow-up [ 23 , 24 ]. The
American College of Chest Physician (ACCP)
guidelines recommend a recipe and duration
of anticoagulation corresponding to thrombus
burden [ 23 ]. Table 19.3 summarizes the current
recommendations and duration of therapy.
Discontinuing anticoagulation presents
another dilemma. Two separate studies showed
an initial benefi t to anticoagulation which was not
sustained when anticoagulation was discontinued
at 8–12 or 30 days. With duration of 45 days, anticoagulation benefi ts were sustained. Presence of
residual thrombus on duplex scan at 4 weeks is not
an indication for ongoing anticoagulation [ 24 ].
Extrapolating from the DVT literature, D-dimer
could perhaps be useful to distinguish high from
low recurrence risk. Although not perfect, if the
result is positive at the end of anticoagulation,
recommendations would be to maintain systemic
anticoagulation and repeat in 1–2 months. If the
result is negative, it is recommended that anticoagulation be discontinued with plan to repeat the
testing 1 month later. In the PROLONG trial in
patients with venous thromboembolism, D-dimer
was assessed every 2 months for a year after
discontinuing anticoagulation. In patients with
persistent elevations of D-dimer after stopping
anticoagulation, the recurrence risk was 27 % per
year [ 25 ]. Patients with isolated superfi cial phle-
bitis will present with or without varicose veins.
Some may declare their respective thrombophilia
risk with persistently elevated D-dimer levels. It
is recommended that each patient with STP be
assessed carefully for ongoing thrombosis risk
and care tailored accordingly [ 25 – 41 ].
19.9.3.2 Anti-infl ammatory Agents
Nonsteroidal anti-infl ammatory agents (NSAIDS)
are effective in reducing the pain and infl ammation of STP. In a pilot program conducted by the
Enoxaparin Study Group, 427 patients were randomized to placebo, enoxaparin, and tenoxicam.
Although there were no signifi cant differences
between the active treatment arms, when compared to placebo, each active arm demonstrated
a meaningful reduction in the incidence of DVT
[ 42 ]. At the present time, the role of NSAIDS
should be reserved for patients with iatrogenic
STP, tributary vein clot with normal saphenous
trunks, or who are low risk for signifi cant clot
extension.
19.9.3.3 Role of Antibiotics
The acute infl ammatory response commonly
seen with superfi cial phlebitis can raise concerns over a potential infectious process
(Fig. 19.1 ). Contrary to general appearance,
these painful superfi cial lesions are almost
always sterile [ 7 ]. Fever, leukocytosis, and tox-
icity suggest an infectious process and septicemia. Patients with suppurative thrombophlebitis
require open drainage and broad spectrum antibiotics. Unless the phlebitis is of the suppurative
type or accompanied by clinical ascending lymphangitis, there is no indication for the use of
antibiotics [ 3 , 28 ].
19.9.4 Surgical Intervention
19.9.4.1 Incision and Drainage
In cases where bulbous varices are acutely
infl amed, painful, and fl uctuant, symptoms may
be rapidly relieved with local incision and drainage. After cleansing the area, local anesthesia
may be infi ltrated with a small needle allowing
for small incisions or punctures to be made over
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Fig. 19.13 Decreasing
infl ammation following local
surgical removal of STP
273
the regions of fl uctuance. Once the punctures are
made, the physician may effectively expel the
superfi cial thrombus [ 25 ]. This minor in-offi ce
procedure is very well tolerated by patients; it
serves to dramatically reduce infl ammation and
pain, with added benefi t if reducing risk of pronounced hyperpigmentation over the affected
region (Fig. 19.13 ).
19.9.4.2 High Ligation and Stripping
Debate exists as to whether surgical intervention
versus conservative medical therapy with LMWH
or anti-infl ammatories offers a better outcome
and reduction in VTE events [ 23 ]. In reality, the
best answer may come down to the combination
of patient and physician preference. In the only
level I trial, Belcaro et al. compared surgical to
medical therapy. Results were comparable, yet
the surgical group employing high ligation, stripping, and perforator ligation had the best response
with no thrombus extensions at 3 months and a
single event at 6 months. Although no VTE
events were noted in the medical arms, four
(2.7 %) patients in the surgical arm suffered
extension of thrombus into the deep venous system, but there were no pulmonary emboli [ 26 ].
In a prospective study, 20 consecutive
patients with thrombophlebitis within 1 cm of
the SFJ were managed nonoperatively. Ascer
et al. found a 40 % incidence of concurrent
DVT in the sample. Medical therapy included
bed rest, leg elevation, and full anticoagulation
for 6 months. No pulmonary emboli, no recurrences, and no complications from anticoagulation were noted [ 27 ]. In a review by the
American College of Chest Physicians, when
surgical management is compared to medical
management, the surgical therapy (high ligation, surgical stripping, +/− perforator ligation)
is more than threefold more costly and carries a
higher rate of VTE complications. As a result,
present ACCP recommendations favor medical
treatment with anticoagulants over surgical
treatment (grade 1B) [ 43 – 46 ].
19.9.4.3 Warm Versus Cold
Compresses
Warm moist compresses have been recommended
to help manage superfi cial thrombophlebitis for
decades, yet there is little evidence besides common practice to support its use [ 7 ]. According to
present day indications for heat therapy, acute
infl ammation is a relative contraindication for
using warm compresses. There is no mistaking
the infl ammatory response that is commonly
seen. Cold packs or ice are indicated for acute
infl ammatory processes and for acute injuries,
the local tissue effect reduces infl ammation and
pain. There is little evidence to support benefi t
from the use of warm compresses. Ultimately the
use of warm compresses or ice packs is dependent
upon provider choice.
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Case 4. DH (Fig. 19.14 )
DH is a 28-year-old white, male with chief
complaint of left leg pain for 3 weeks.
Symptoms include aching, burning, and
swelling. He reports he has had repeated
fl ares involving each lower extremity where
regions become infl amed and fi rm to the
touch. DH was recently evaluated in the
emergency department, where he was prescribed cephalexin. He reports no diagnosis
was shared, and no imaging study has been
performed. Past medical history is unremarkable with the exception of previous bouts as
described above. Family history is positive
for varicose veins, but no known thrombophilia or VTE. No previous surgeries. Social
history reveals casual alcohol and tobacco
use. DH is actively employed in the golf
maintenance industry, walking as much as
6 h per day. Review of systems was otherwise negative.
Vital signs reveal a respiratory rate of 14,
heart rate of 61, a blood pressure of 139/58,
oxygen saturation of 99 %, and a BMI of
31.4. Physical exam was unremarkable with
the exception of a faint pink hue along the
inseam of the left thigh. There were no visible varicosities or palpable cord. No edema
was noted.
Duplex study reveals a noncompressible
GSV from the level of the knee to the SFJ.
There was no sign of DVT or evidence of deep
or saphenous vein refl ux. The vessel diameters
are within normal limits.
List the risk factors DH possesses for
developing VTE?
Fig. 19.14 Case #4 – Acute STP with no physical
fi ndings of venous pathology
Assuming DH had previously normal
saphenous veins, how would your management strategy change?
Which of the following are strongly recommended for this presentation?
Ambulation
Therapeutic compression therapy
Systemic anticoagulation
Surgical ligation of the saphenofemoral
junction
Thrombophilia testing
Intravenous antibiotic
Warm compresses
19.10 Management Strategies
Once the diagnosis is made, whether isolated STP
or combined STP with or without VTE, patients
should be effectively counseled. Many patients
may have never been burdened by their veins,
and now they are found to have a painful condition that has potential life or limb threatening
complications. Increasing leg pain, swelling,
sudden chest pain, or dyspnea are all indications
for emergent evaluation and potential change in
management. This may be a tremendous amount
of information for a patient to digest. Building
patient expectations and follow-up must be effectively managed. The patient’s primary care physician may be unaware of complications associated
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with STP. In this instance, opportunities exist to
bring an elevated awareness to complications of
venous stasis.
Not all patients with superfi cial phlebitis are
alike. Differing presentations were shared in the
cases above, but there are many other examples.
This section summarizes recommendations in
three distinct groups of patients and outline proposed best practice guidelines.
19.10.1 Superfi cial Thrombophlebitis
Isolated to Tributaries
These patients often have significant discomfort from inflamed superficial varices,
yet they generally possess the lowest risk
for potential VTE complications. Therapy in
this category of patients should be supportive
involving each of the following: ambulation,
properly fitted compression stocking or wraps
20–30 mmHg or higher, anti-inflammatories,
and local incision and drainage of inflamed
varices if symptoms warrant. Time should be
taken to educate patients arming them with
awareness of warning signs should symptoms
worsen. Ideally, these patients should be followed up with repeat duplex study over the
following weeks.
19.10.2 Superfi cial Thrombophlebitis
with Saphenous Vein
Involvement in the Presence
of Varicose Veins
Patients with saphenous vein involvement in the
presence of varicose veins are at risk for extension of existing thrombus and VTE complications. For this reason, near-term follow-up with
ultrasound within 5–10 days is recommended. At
present, the ACCP recommends prophylactic to
intermediate dosing of LMWH or fondaparinux
for a minimum of 45 days, when thrombus
involves the saphenous veins or approximate
the saphenofemoral/saphenopopliteal junctions.
This author typically anticoagulates patients with
acute saphenous thrombosis whether or not it is
close or long enough. Additional recommended
therapy includes ambulation, properly fi tted
compression, and local incision and drainage if
symptoms warrant.
19.10.3 Superfi cial Thrombophlebitis
with VTE Complications at
Presentation/STP Without
Varicose Veins
As with the category above, these patients
should walk, wear properly fitted compression, and begin anticoagulation according to
ACCP guidelines for VTE. Signs and symptoms suggesting a need for prompt reassessment should be shared. What makes this group
somewhat unique is the potential to possess an
underlying hypercoagulable cause for their
present condition. In the interest of preventing
future VTE, risk may be mitigated by
promoting healthy vein habits and considering
thrombophilia work-ups on those with clear
indications.
19.10.4 Unusual Sites of Superfi cial
Thrombophlebitis
19.10.4.1 Upper Extremity STP
Superfi cial thrombophlebitis of upper extremity veins is most commonly encountered as a
complication of intravenous infusions and, at
times, drugs that lead to infl ammation at the
infusion site. Rarely associated with VTE, the
ACCP guidelines recommend oral or topical
anti- infl ammatory agents until symptoms resolve
(grade 2B). Anticoagulation for this disorder is
not recommended (grade 1C).
19.10.4.2 Mondor’s Disease
This is classically reported as superfi cial thrombosis of breast veins along the anterolateral
aspect. Symptoms include pain, tenderness, and
erythema. On physical exam a cord is commonly
felt, and the skin is tensed or dimpled as the ipsilateral arm is elevated. This may occur following
surgery, with malignancy (12 %), or hormonal
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M.W. Schul
and hereditary thrombophilia. Care is usually
supportive with anti-infl ammatories, cold compresses, and time.
Superfi cial thrombophlebitis may also be
seen in the superfi cial dorsal vein of the penis.
Although rare, the presentation may be related
to prolonged excessive sexual intercourse, hernia operations, as well as other concomitant
thrombotic events. Duplex ultrasonography
confi rms noncompressibility of the vessel and
permits assessment of adjacent deep and superfi cial vessels. Treatment is supportive with antiinfl ammatory agents, reserving dorsal penile
surgery for refractory cases.
19.10.4.3 Septic Thrombophlebitis
Suppurative thrombophlebitis is a life-threatening condition frequently associated with septicemia [ 8 ]. Patients may present with grossly
infl amed superfi cial vein, fever, leukocytosis,
and signs of sepsis. The most common source
of infection stems from an intravenous puncture,
yet soft tissue and solid organ infections have
been reported [ 27 ]. The mainstay of therapy is
urgent surgical excision and broad spectrum
antibiotics.
19.11 Conclusion/Summary
Superfi cial thrombophlebitis is a common condition associated with substantial morbidity, though
less than that seen with femoropopliteal deep
vein thrombosis. The best practice may be debatable at present, yet principles to protect patients
from complications of venous stasis remain of
paramount importance. Benign neglect of heat,
elevation, and bed rest are no longer acceptable
options. In fact, present management strategies
largely parallel those used for deep vein thrombosis, varying only in the use and duration of
anticoagulation.
Case Study Questions and Considerations
Case 1
Does this patient have the working diagno-
sis of STP?
The short answer is yes.
What are the clinical features of STP?
This patient possesses acute onset, fi rm,
painful, infl amed varices, along the medial
thigh. Other potential fi ndings include
red streaking, fl uctuance over cluster of
varices, a palpable cord, and presence of
edema. Of important note, the most proximal point of thrombus by physical exam is
on average 15 cm short of most proximal
point by duplex ultrasound.
What is the differential diagnosis of STP?
Table 19.1 provides an overview of
alternative considerations.
Does this patient have risk factors for
DVT?
The risk factors of STP are the same as
DVT as shown in Table 19.2 .
What tests are indicated at the initial
evaluation of clinically suspected STP?
The noninvasive, yet highly accurate
duplex exam is indicated for every
patient with clinical fi ndings consistent
with STP. Only upon duplex testing
does it become possible to optimize
treatment while reducing the risk for
VTE if it has not already occurred.
Case 2
What risk factors does JD possess that
place him at risk for developing STP?
Prolonged immobilization and known
history of varicose veins.
What risk factors does JD possess that
place him at risk for VTE?
If one was to consider both the Lutter
and Quenet studies, age >60, male sex,
sudden onset, and recent immobiliza-
tion are JD’s risks for VTE.
Describe a practical approach to evaluate
JD and guide his treatment.
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Everything starts with a systematic
assessment of the limb(s) with duplex
ultrasonography. If anticipating the
implementation of anticoagulation, ini-
tial laboratory tests may be ordered.
Do you agree with the urgent care recommendations of anti-infl ammatory agents, an
antibiotic, and compression therapy? Please
explain.
Anti-infl ammatories? If there is no indi-
cation for anticoagulation, anti-infl am-
matories may prove quite helpful in
reducing symptoms and arguably mini-
mizing the risk of thrombus extension.
Antibiotics? Unless JD is toxic, no anti-
biotics are indicated as the lesions are
sterile by nature.
Compression therapy? Unless a contrain-
dication exists, compression is indicated
for nearly any vein-related concern or for
the swollen limb pending diagnosis. The
reality is that if anticoagulation is to
occur, stockings may be applied at the
same stage as the initial dose of LMWH.
Case 3 (Fig.
19.12 )
What is the likelihood that JA has already
passed pulmonary emboli to explain his
dyspnea?
According to series by Verlato and
Sobreira, the risk approximates 25–33 %
simply by possessing STP at the level of
the saphenofemoral junction.
What risk factors suggest JA is at higher
risk of developing VTE complications?
He is male, obese, and reported an acute
onset of symptoms.
Are any further diagnostic tests indicated?
This is debatable, as JA was hemodynam-
ically stable and did not appear grossly ill.
The recommended duration of anticoagu-
lation varies signifi cantly however (e.g.,
4 weeks for isolated STP of the GSV ver-
sus 6 months for patients with pulmonary
embolus). If there is any doubt as to the
question of PE, perfusion scanning or spi-
ral computed tomography works well in
establishing the diagnosis. In this instance,
it was the acute onset of symptoms associated with dyspnea that led to spiral
computed tomography (CT) scanning to
confi rm multiple pulmonary emboli.
What management strategies would you
consider?
Reimaging in near term (3 months)
Although repeat duplex scanning did
not signifi cantly change in the near
term, complete recanalization was
seen at 3 months. All of the previously
affected vessels were now refl uxing and
thermal ablation was successfully performed. Twelve months later, his GSV
is no longer detectable by ultrasound.
Compression therapy/ambulation
JA continues to make compression a
routine part of his daily life as a farm
machinery salesman. He is losing
weight and is making walking a daily
part of his exercise regimen.
Anticoagulation
JA was given LMWH and transitioned
to warfarin which he continues to take
today. He was found to have thrombophilia, and multiple bouts of phlebitis
with complication of PE have led him
and his hematologist to favor longterm anticoagulation. If he had not
been diagnosed with PE, he may not
have undergone thrombophilia testing.
Thrombophilia testing
Multiple bouts of phlebitis with complications of pulmonary embolus in a
young patient led to the thrombophilia
work-up. The patient was incorporated into the decision making and
understood the potential ramifi cations
should a signifi cant fi nding be noted.
He also recognized that he could have
a yet to be discovered disorder should
the work-up have proven negative.
Case 4 (Fig . 19.14 )
List the risk factors DH possesses for
developing VTE
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M.W. Schul
DH is male, he smokes, he has no physical fi ndings of venous disease, and yet
he has had multiple bouts of phlebitis.
Assuming DH had previously normal
saphenous veins, how would your management strategy change?
In this instance, DH should be considered
at risk for an underlying thrombophilia.
He reports multiple bouts of phlebitis and
is young. The work-up identifi ed DH as
being homozygous for Factor V Leiden.
Which of the following are strongly recommended for this presentation?
Ambulation: every patient should be
encouraged to walk.
Therapeutic compression therapy: every
patient should be fi tted with at minimum
calf high compression therapy. It is our
practice to compress the areas involved
(e.g., thigh-high, panty height, or Capri-
style stockings could each be employed
in this case).
Systemic anticoagulation: STP approxi-
mated the saphenofemoral junction
(SFJ) and thus LMWH was initiated
acutely with subsequent transition to
warfarin.
Surgical ligation of the SFJ: although
this may be a regional choice, medical
therapy is preferred in this instance.
These patients are already hypercoagulable and the VTE risk is higher when
compared to medical therapy.
Thrombophilia testing: in this instance,
the history and age of the patient led
to a candid discussion. The risks were
explained and the patient wanted to
know if there was a reason for recurrent bouts of phlebitis. In this instance,
a rather important thrombophilia was
identifi ed in homozygous factor V
Leiden (FVL).
Intravenous antibiotics: antibiotics are
not indicated unless septic thrombophlebitis is suspected.
Warm compresses: warm or cold compresses are a reasonable option to help
provide symptomatic relief.
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