Superficial thrombophlebitis

What is superficial thrombophlebitis?

Superficial thrombophlebitis occurs when a superficial vein (usually the long saphenous vein of the leg or its tributaries) becomes inflamed and the blood within it clots. It may be spontaneous or associated with one or more risk factors - eg, varicose veins.

It is usually a benign self-limiting disease but it can be difficult to treat and slow to resolve.

How common is superficial thrombophlebitis? (Epidemiology)

This is a very common condition and, although figures are difficult to find. Some reports estimate an incidence of between 3-11% of the general population.¹

It has a female preponderance, and seasonal variation (more common in warmer months) has also been reported. Women make up 50-70% of reported cases of superficial venous thrombophlebitis.²³

Risk factors for superficial thrombophlebitis¹

The three cardinal risk factors for deep vein thrombosis (Virchow's triad) are:

• Damage to the blood vessel wall (as a result of trauma, infection, or inflammation), including varicose veins.

• Stasis of blood flow.

• Hypercoagulability of blood.

These are also thought to be risk factors for superficial venous thrombophlebitis but the relevance of hypercoagulability has been questioned. ²

Other specific risk factors include:

• Obesity.

• Thrombophilia.

• Previous history of superficial vein thrombosis.

• Previous history of deep vein thrombosis or pulmonary embolism. ²

• Smoking.

• Oral contraceptives.

• Pregnancy.⁴

• Intravenous drug abuse.

• Intravenous infusion (especially if an irritant substance was infused).⁵

• Varicose veins.

Superficial thrombophlebitis symptoms

There are various different presentations of superficial thrombophlebitis:

• Superficial thrombophlebitis usually occurs in the lower extremities but occurs also in the penis and the breast (Mondor's disease).⁶

• Traumatic thrombophlebitis follows an injury. There is a tender cord along the course of a vein and bruising.

• Thrombophlebitis frequently occurs with an intravenous cannula. Either the cannula or the infusion, including drugs, may have caused the inflammation. A small lump may appear days or weeks after the cannula has been removed and it can take months to resolve completely. The common sites coincide with those of common medical interventions (arm or neck with external jugular vein cannulation).

• Iatrogenic chemical phlebitis is deliberately produced by sclerotherapy.

• Thrombophlebitis in a varicose vein develops as a tender hard knot in the vein. There is often erythema, and bleeding may occur as the reaction extends through the vein wall. It is common with venous stasis ulcers.

• Septic phlebitis usually occurs with long-term use of an intravenous cannula. It is also common in intravenous drug abusers who use dirty equipment and have poor technique.

• Suppurative thrombophlebitis is a serious complication when there is pus in the vein and septicaemia may develop.⁷

• Thrombosis of a haemorrhoid or perianal haematoma is a superficial thrombophlebitis. Incision and removal of the thrombus relieves the condition.

Signs

• There is redness with tenderness along the vein with swelling.

• Spontaneous thrombophlebitis usually develops in the greater saphenous vein, often with varicose veins.

Differential diagnosis

• Cellulitis.

• Deep vein thrombosis (DVT).

• Lymphangitis.

• Ruptured medial head of gastrocnemius.

• Tendonitis.

Diagnosing superficial thrombophlebitis (investigations)

• Further investigation may be warranted to assess for an underlying DVT.⁸

• If a septic cannula is suspected, it should be removed and sent for culture.

Associated diseases

• Recurrent thromboses in superficial veins at various sites are called migratory thrombophlebitis. This is a pointer for malignancy, especially carcinoma of the tail of pancreas.^{9 10}

• Phlebitis occurs in diseases associated with vasculitis, such as polyarteritis nodosa and Buerger's disease, which Buerger reported in 1909.

Management of superficial thrombophlebitis¹

General measures

• Elastic support of the limb reduces swelling and eases discomfort.

• Severe thrombophlebitis does not usually require bed rest unless there is severe pain on movement. The affected extremity should be elevated if possible and large, warm compresses may be applied, although the evidence base for their effectiveness is limited and care must be taken to avoid burning the patient.¹¹

• Exercise reduces pain and the possibility of DVT. Only in cases in which pain is very severe is bed rest necessary. DVT prophylaxis should be established in patients with reduced mobility.¹²

• Keeping the leg elevated when sitting may improve venous blood flow and reduce swelling.

Pharmacological

• Topical anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls mild symptoms.

• Otherwise an oral non-steroidal anti-inflammatory drug (NSAID) and/or paracetamol will be required for pain relief.

• Topical heparin has been shown to have some limited benefit in treating superficial venous thrombosis but studies have been poor. ¹³

• Low molecular weight heparin (LMWH) and fondaparinux have been shown to reduce the risk of superficial vein thrombosis extension and recurrence.

• Prophylactic fondaparinux given for 45 days appears to be an effective option for superficial thrombophlebitis for most people.¹⁴

• A Cochrane review in 2018 suggests that 45 days of subcutaneous fondaparinux should be offered to all patients with:

  • A superficial thrombophlebitis extending more than 5cm in length.

  • A superficial thrombophlebitis proximal to the knee, particularly within 10cm of the saphenofemoral junction.

  • Severe symptoms.

  • Greater saphenous vein involvement.

  • Previous VTE or previous superficial thrombophlebitis.

  • Active malignancy.

  • Recent surgery.¹⁵

• Fondaparinux significantly reduces the risk of symptomatic venous thromboembolism and may be considered in people at increased risk of a DVT or PE - eg, those with superficial thrombus near the saphenofemoral junction.

Antibiotics are only required if there is evidence of infection.

Surgical

If there are recurrences of the thrombophlebitis associated with extensive varicose veins, they should be excised.

Complications of superficial thrombophlebitis¹

• Extension into the deep veins, with possible development of deep vein thrombosis and/or pulmonary embolism (PE).^{16 17}

• Damage to valves may lead to varicose veins.

• Suppurative phlebitis can lead to metastatic abscesses and septicaemia.

• Hyperpigmentation over the vein.

• Persistent firm nodule in subcutaneous tissues at the affected site.

Superficial thrombophlebitis prognosis¹

• The prognosis is usually good for uncomplicated superficial thrombophlebitis. Symptoms generally subside in 1-2 weeks. Hardness of the vein may persist for several weeks to months.

• The risk of recurrence ranges between 1.6-12.2% in treated cases and 3.3-36.7% in untreated cases, depending on the presence or absence of underlying risk factors.

• It rarely leads to PE, although it can occur if the process extends into a deep vein.

• People with superficial venous thrombosis do not seem predisposed to develop DVT but superficial venous thrombosis does frequently occur in association with DVT, especially with stasis ulceration around the ankle.

• Where venous thromboembolism precedes thrombophlebitis, there is an increased risk of recurrent VTE.¹⁸