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Current Approach in the Management of Superficial Venous Thrombophlebitis: When to Be Aggressive




Study published in 2010 finds 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm in length underwent ultrasonography.

When to be more aggressive in the approach to treatment to superficial venous thrombophlebitis (SVT):

  • Extensive SVT anywhere in the leg
  • SVT over 5 cm in length when found in the thigh
  • SVT in the context of risk factors such as a history of DVT/PE, malignancy or thrombophilia, inpatient status or when in nonvaricose viens

What Should Be Done When Aggressive Treatment Is Indicated?

  • Obtain an ultrasound to determine the extent of thrombosis
  • Begin on LMWH at prophylactic doses (such as enoxeparin 40 mg sq qd) or therapeutic doses (such as enoxeparin1mg/kg q 12h if normal renal function) continued for a minimum of four weeks. Depending on the site and extent of involvement, treatment may be extended up to three months and may be transitioned to warfarin.

Why the Aggressive Approach?

While superficial venous thrombophlebitis has long been considered a limited clinical condition of lesser importance, this perception has changed in recent years as several studies have demonstrated that extension to deep veins occurs in 7.3% to 44% of patients, with not a small incidence of pulmonary embolism.

This new respect for SVT was confirmed in a relatively large prospective study published in 2010 in the Annals of Internal Medicine where 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm in length underwent ultrasonography. Among 844 patients with SVT at inclusion, 24.9% also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism.

In this same study, among 600 patients without DVT or pulmonary embolism at inclusion who were eligible for a three-month follow-up, 10% developed thromboembolic complications at three months pulmonary embolism, three (0.5%); DVT, 15 (2.8%); extension of SVT, 18 (3.3%); and recurrence of SVT, 10 (1.9%), despite 90% of the patients having received anticoagulants.

When ultrasound is not immediately available, it is acceptable to begin anticoagulation with LMWH as you await results of an ultrasound.

It is important that the patient remain active and not be limited to bed rest (as is also the case with DVT). Calf or thigh length 20-30 mm graduated medical compression stockings are indicated when tolerated.

When a patient presents with a firm and tender cord of indurated vein in the lower leg, which is less than 5 cm, the traditional approach of compresses and anti-inflammatories continues to serve in management. The patient should remain active.

In all patients the leg should be rechecked a week later.

The above recommendations differ from infusion thrombophlebitis where anticoagulation is not recommended. If symptomatic, recommendations are for topical diclofenac gel, oral diclofenac or other NSAID until resolution of symptoms or up to two weeks.

Aspirin is not recommended as prophylaxis for venous thromboembolic disease. Aspirin is useful in preventing arterial thrombosis, not venous and is not indicated.

It is helpful to consider the presence of extensive superficial phlebitis as an independent marker for underlying hypercoagulability, when there is no underlying varicose vein disease, malignancy or autoimmune disease, particularly when the saphenous trunk is involved. Up to 35% will be found to have coagulopathy.

References

  1. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians   Evidence-Based Clinical Practice Guidelines (8th Edition), 2008
  2. Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010; 152:218.
  3. Predictive Factors for concurrent deep-vein thrombosis and symptomatic venous thromboembolic recurrence in case of superficial venous thrombosis. The OPTIMEV study. Thromb. Haemost. 2011 January;105(1):31-9. Galanaud JP, et al.
  4. Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh ACCP Conference of Antithrombotic and Thrombolytic Therapy. HR Bueller, et al. Chest 2004;126;401-428.

MDNews March/April 2012, Knoxville


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