Thrombophlebitis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Synonyms and keywords: White Leg; phlebitis
Overview
Thrombophlebitis is inflammation of a vein, usually associated with the formation of a thrombus within the superficial venous system. It can occur in any superficial venous system, but most commonly in the lower limbs. Symptoms of thrombophlebitis include pain along the course of the vein, redness, itching and swelling around the site of thrombophlebitis. The treatment of thrombophlebitis consists of compression stockings, analgesia, as well as anticoagulants. The most feared complications are DVT and PE.
Historical Perspective
- In 1913, Burnham AC discussed thrombophlebitis in postoperative patients.[1]
- Historically, the treatment of thrombophlebitis was purely surgical and consisted of removal of the thrombosed vein.[2]
Classification
Thrombophlebitis can be classified according to the cause into:[3]
| Type of Thrombophlebitis | Description |
|---|---|
| Sterile | Most common type of thrombophlebitis |
| Traumatic | Associated with the following conditions:
|
| Infective | Mostly due to prolonged IV cannulation |
| Migratory | Recurrent thrombophlebitis at various sites. Associated with an underlying malignancy, most commonly adenocarcinoma of the pancreas |
Thrombophlebitis may also be classified according to the site into:[4]
- Superficial thrombophlebitis of the lower limb: most common location and it involves the great and short saphenous veins.
- Superficial thrombophlebitis of the arms
- Superficial thrombophlebitis of the breast: also known as Mondor's disease
- Superficial thrombophlebitis of the abdominal wall
Pathophysiology
Pathogenesis
The pathogenesis of thrombophlebitis is related to 3 important factors:[3][5][6]
These 3 factors (known as Virchow's triad) predispose to thrombus formation within the veins and subsequently to thrombophlebitis.
Associated Conditions
Thrombophlebitis may be associated with the following conditions:
- Coagulation abnormalities:[3][7]
- Thromboangiitis obliterans (Buerger's Disease)[8]
- Underlying malignancy, especially adenocarcinoma of the pancreas in the case of migratory thrombophlebitis[9][10]
Causes
Common Causes
- Deep vein thrombosis
- Drug side effects
- Intravenous infusion
- IV catheter infection
- Levamisole-induced vasculopathy
- Penicillin G potassium infusion
- Thromboangiitis obliterans
- Thrombophlebitis migrans
- Varicose veins
- Vein injury
Differentiating Thrombophlebitis from other Diseases
Thrombophlebitis must be differentiated from the following conditions causing pain, swelling and palpapable mass in the extremities:[11][12][13][14]
| Condition | Predilection Site | Pain | Redness | Warmth | Swelling of Surrounding Tissue | Itching | Palpable Mass | Systemic Symptoms |
|---|---|---|---|---|---|---|---|---|
| Varicose veins | Lower limb | + | - | - | + | + | - | - |
| Deep vein thrombosis | Lower limb | + | + | + | + | - | - | Systemic symptoms are present if DVT is complicated by PE. These include: |
| Cellulitis | No sites of predilection | + | + | + | + | - | - | |
| Lymphangitis | Commonly the extremities | + | + | - | + | - | - | May be accompanied by: |
| Lymphedema | Lower limb | - | - | - | + | - | - | |
| Baker's cyst | Lower limb | +/- | - | - | + | - | Sensation of a water-filled balloon on the posterior aspect of the knee and calf | - |
| Polyarteritis nodosa | Cutaneous PAN most commonly involves
the lower limb |
+ | - | - | - | - | Nodules | |
| Ruptured medial head of gastrocnemius | Lower limb | + | - | - | + | - | Painful lump at the site of rupture | - |
Epidemiology and Demographics
Epidemiology
Incidence
- The incidence of thrombophlebitis is estimated at 100 per 100,000 cases.[4][15]
- Thrombophlebitis is 6 times more common than DVT.[4]
Demographics
Age
- Thrombophlebitis is more common in elderly.[4]
Risk Factors
The following are associated with an increased risk of thrombophlebitis:[3][5][6][4]
- Chronic venous disease, such as varicose veins (most common risk factor)[16][17] and chronic venous insufficiency
- Venous thrombosis, whether a prior history or current DVT[5]
- Venous stasis, associated with prolonged immobility and prolonged surgery
- Hypercoagulable states, such as malignancy[16], pregnancy and the use of estrogen-based hormone therapy[18]
- Trauma to the vessel, such as IV cannulation, sclerotherapy and surgical ablation
- Obesity
Natural History, Complications and Prognosis
Natural History
Thrombophlebitis was thought of as a benign condition. However, if left untreated, thrombophlebitis can recur or extend to involve the deep venous system. DVT can still complicate 10% of cases, despite treatment.[19]
Complications
Complications of thrombophlebitis include:[3][20][21][22][23]
- Venous thromboembolism and subsequent pulmonary embolism: this is especially common when superficial thrombophlebitis occurs at the junction with the deep venous system[24][25][26][27][28][29]
- Hyperpigmentation of the skin overlying the affected vein
- Infection and abscess formation
Prognosis
The prognosis of thrombophlebitis is generally good with medical treatment. However, despite treatment, DVT can complicate about 10% of cases of thrombophlebitis.
Screening
There are no screening recommendations for thrombophlebitis.[30]
Diagnosis
History and Symptoms
The following symptoms are often (but not always) present in patients with thrombophlebitis:[31][4][15]
- Pain along the course of the affected vein
- Pain on touch of the affected vein (tenderness)
- Skin redness (erythema)
- Itching
- Swelling of the surrounding tissue (edema)
- Elevated temperature (fever) may or may not be present
Physical Examination
Examination of the skin and affected area reveals the following:[4][15][31]
- Tenderness along the course of the affected vein
- Erythema of the skin surrounding the vein
- Edema of the surrounding tissue
Laboratory Findings
D-Dimer
D-Dimer is not a useful laboratory test in the diagnosis of isolated cases of superficial thrombophlebitis. However, it may be useful in the case of a concomitant DVT.[4]
Ultrasound
Venous Duplex Ultrasound
Although the diagnosis of thrombophlebitis is mostly clinical, venous Duplex ultrasound is considered the imaging of choice in suspected cases.[4][23] Venous Duplex ultrasound can identify the following:
- Thickening of the wall of the vein, which may be associated with perivenous or subcutaneous edema
- A thrombus may or may not be present within the superficial venous system[20]
- DVT may exist along with superficial thrombophlebitis, especially when thrombophlebitis involves the proximal great saphenous vein[5][24][32][33][20][22][25][34][35][21][26]
- Ruling out other pathologies such as a popliteal cyst or muscle mass, which may be responsible for the patient's complaints[36][37]
Other Imaging Findings
There are no other imaging findings associated with thrombophlebitis.
Other Diagnostic Studies
There are no other diagnostic studies associated with thrombophlebitis.
Treatment
Medical Therapy
The following interventions are used as a mainstay in treatment of thrombophlebitis:[3][19][38][23]
Nonsteroidal Anti-Inflammatory Drugs
All NSAIDs have the same effect in the treatment of thrombophlebitis.[39] They are effective in reducing the pain, and decrease the extension of thrombosis.[40][15]
Anticoagulation
- Unlike minimal thrombophlebitis that can be resolved using conservative measures and NSAIDs, severe cases need anticoagulation therapy to prevent thrombus extension.[41]
- Low molecular weight heparin is considered the treatment of choice, and proved to be superior to the NSAID in preventing extension of superficial thrombophlebitis.[41][42]
- Other anticoagulants which may be used include warfarin, unfractionated heparin or fondaparinux.[41]
Topical Agents
Some topical anti-inflammatory agents (e.g. diclofenac gel) has been found to reduce the pain, and help resolution of the inflammation.
Antibiotics
When suppurative thrombophlebitis is suspected, antibiotic treatment should be started.
Surgery
Conservative measures and medical therapy are considered the first line treatment for patients with thrombophlebitis. However, patients with recurrent thrombophlebitis are candidates for surgical intervention, such as venous stripping or ligation.[4][38]
Prevention
Primary Prevention
The following preventive measures can be done to decrease the incidence of thrombophlebitis:[3][5][6][4]
- Encourage early mobilization after surgery to prevent venous stasis
- Avoid prolonged cannulation or change cannula after no more than 48 hours
- Consider anticoagulants for patients with coagulation disorders or hypercoagulable states
Secondary Prevention
Medical therapy with anticoagulants can decrease the rate of recurrence of thrombophlebitis.
References
- ↑ Burnham AC (1913). "II. Postoperative Thrombophlebitis". Ann. Surg. 57 (2): 151–62. PMC 1407408. PMID 17862964.
- ↑ Homans J (1928). "THROMBOPHLEBITIS OF THE LOWER EXTREMITIES". Ann. Surg. 87 (5): 641–51. PMC 1398549. PMID 17865873.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Nasr H, Scriven JM (2015). "Superficial thrombophlebitis (superficial venous thrombosis)". BMJ. 350: h2039. PMID 26099257.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Scott G, Mahdi AJ, Alikhan R (2015). "Superficial vein thrombosis: a current approach to management". Br. J. Haematol. 168 (5): 639–45. doi:10.1111/bjh.13255. PMID 25521017.
- ↑ 5.0 5.1 5.2 5.3 5.4 Guex JJ (1996). "Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis". Dermatol Surg. 22 (4): 378–82. PMID 8624665.
- ↑ 6.0 6.1 6.2 Samlaska CP, James WD (1990). "Superficial thrombophlebitis. II. Secondary hypercoagulable states". J. Am. Acad. Dermatol. 23 (1): 1–18. PMID 2195069.
- ↑ Martinelli I, Cattaneo M, Taioli E, De Stefano V, Chiusolo P, Mannucci PM (1999). "Genetic risk factors for superficial vein thrombosis". Thromb. Haemost. 82 (4): 1215–7. PMID 10544900.
- ↑ Olin JW (2000). "Thromboangiitis obliterans (Buerger's disease)". N. Engl. J. Med. 343 (12): 864–9. doi:10.1056/NEJM200009213431207. PMID 10995867.
- ↑ Diaconu C, Mateescu D, Bălăceanu A, Marcu M, Jianu V, Stănică A (2010). "Pancreatic cancer presenting with paraneoplastic thrombophlebitis--case report". J Med Life. 3 (1): 96–9. PMC 3019029. PMID 20302205.
- ↑ Varki A (2007). "Trousseau's syndrome: multiple definitions and multiple mechanisms". Blood. 110 (6): 1723–9. doi:10.1182/blood-2006-10-053736. PMC 1976377. PMID 17496204.
- ↑ Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
- ↑ Füeßl HS (2016). "[Emergency checklist: Acute lymphangitis]". MMW Fortschr Med (in German). 158 (11): 65. doi:10.1007/s15006-016-8384-9. PMID 27271418.
- ↑ Chung E, Pulitzer MP, Papadopoulos EB, Papanicolaou GA, Babady NE, Marchetti MA (2015). "Lymphangitic papules caused by Nocardia takedensis". JAAD Case Rep. 1 (3): 126–8. doi:10.1016/j.jdcr.2015.03.001. PMC 4808715. PMID 27051706.
- ↑ lymphangitis Mandell, GERALD L. "Mandell, Douglas, and Bennett's." Principles and practice of infectious diseases 7 (1995) Accessed on October 12,2016
- ↑ 15.0 15.1 15.2 15.3 Di Nisio M, Wichers IM, Middeldorp S (2013). "Treatment for superficial thrombophlebitis of the leg". Cochrane Database Syst Rev (4): CD004982. doi:10.1002/14651858.CD004982.pub5. PMID 23633322.
- ↑ 16.0 16.1 Gillet JL, Allaert FA, Perrin M (2004). "[Superficial thrombophlebitis in non varicose veins of the lower limbs. A prospective analysis in 42 patients]". J Mal Vasc (in French). 29 (5): 263–72. PMID 15738838.
- ↑ De Maeseneer MG (2005). "Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment". Acta Chir. Belg. 105 (2): 145–7. PMID 15906904.
- ↑ McColl MD, Ramsay JE, Tait RC, Walker ID, McCall F, Conkie JA, Carty MJ, Greer IA (1997). "Risk factors for pregnancy associated venous thromboembolism". Thromb. Haemost. 78 (4): 1183–8. PMID 9364982.
- ↑ 19.0 19.1 Di Nisio M, Middeldorp S (2014). "Treatment of lower extremity superficial thrombophlebitis". JAMA. 311 (7): 729–30. doi:10.1001/jama.2014.520. PMID 24549553.
- ↑ 20.0 20.1 20.2 Lutter KS, Kerr TM, Roedersheimer LR, Lohr JM, Sampson MG, Cranley JJ (1991). "Superficial thrombophlebitis diagnosed by duplex scanning". Surgery. 110 (1): 42–6. PMID 1866693.
- ↑ 21.0 21.1 Chengelis DL, Bendick PJ, Glover JL, Brown OW, Ranval TJ (1996). "Progression of superficial venous thrombosis to deep vein thrombosis". J. Vasc. Surg. 24 (5): 745–9. PMID 8918318.
- ↑ 22.0 22.1 Bergqvist D, Jaroszewski H (1986). "Deep vein thrombosis in patients with superficial thrombophlebitis of the leg". Br Med J (Clin Res Ed). 292 (6521): 658–9. PMC 1339644. PMID 3081214.
- ↑ 23.0 23.1 23.2 Sándor T (2017). "[Superficial venous thrombosis. A state of art]". Orv Hetil (in Hungarian). 158 (4): 129–138. doi:10.1556/650.2017.30618. PMID 28116936.
- ↑ 24.0 24.1 Blumenberg RM, Barton E, Gelfand ML, Skudder P, Brennan J (1998). "Occult deep venous thrombosis complicating superficial thrombophlebitis". J. Vasc. Surg. 27 (2): 338–43. PMID 9510288.
- ↑ 25.0 25.1 Hanson JN, Ascher E, DePippo P, Lorensen E, Scheinman M, Yorkovich W, Hingorani A (1998). "Saphenous vein thrombophlebitis (SVT): a deceptively benign disease". J. Vasc. Surg. 27 (4): 677–80. PMID 9576081.
- ↑ 26.0 26.1 Verlato F, Zucchetta P, Prandoni P, Camporese G, Marzola MC, Salmistraro G, Bui F, Martini R, Rosso F, Andreozzi GM (1999). "An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh". J. Vasc. Surg. 30 (6): 1113–5. PMID 10587397.
- ↑ Decousus H, Prandoni P, Mismetti P, Bauersachs RM, Boda Z, Brenner B, Laporte S, Matyas L, Middeldorp S, Sokurenko G, Leizorovicz A (2010). "Fondaparinux for the treatment of superficial-vein thrombosis in the legs". N. Engl. J. Med. 363 (13): 1222–32. doi:10.1056/NEJMoa0912072. PMID 20860504.
- ↑ Belcaro G (1990). "Evolution of superficial vein thrombosis treated with defibrotide: comparison with low dose subcutaneous heparin". Int J Tissue React. 12 (5): 319–24. PMID 2098372.
- ↑ Belcaro G, Nicolaides AN, Errichi BM, Cesarone MR, De Sanctis MT, Incandela L, Venniker R (1999). "Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study". Angiology. 50 (7): 523–9. PMID 10431991.
- ↑ U.S. Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=thrombophlebitis. Accessed on Feb. 15, 2017
- ↑ 31.0 31.1 Gizurarson JG, Filippusson H (2015). "Conjugation of D-glucosamine to bovine trypsin increases thermal stability and alters functional properties". Enzyme Microb. Technol. 75-76: 1–9. doi:10.1016/j.enzmictec.2015.04.005. PMID 26047909.
- ↑ Binder B, Lackner HK, Salmhofer W, Kroemer S, Custovic J, Hofmann-Wellenhof R (2009). "Association between superficial vein thrombosis and deep vein thrombosis of the lower extremities". Arch Dermatol. 145 (7): 753–7. doi:10.1001/archdermatol.2009.123. PMID 19620555.
- ↑ Bounameaux H, Reber-Wasem MA (1997). "Superficial thrombophlebitis and deep vein thrombosis. A controversial association". Arch. Intern. Med. 157 (16): 1822–4. PMID 9290540.
- ↑ Messmore HL, Bishop M, Wehrmacher WH (1991). "Acute venous thrombosis. Therapeutic choices for superficial and deep veins". Postgrad Med. 89 (7): 73–7. PMID 2031032.
- ↑ Skillman JJ, Kent KC, Porter DH, Kim D (1990). "Simultaneous occurrence of superficial and deep thrombophlebitis in the lower extremity". J. Vasc. Surg. 11 (6): 818–23, discussion 823–4. PMID 2193177.
- ↑ Quéré I, Leizorovicz A, Galanaud JP, Presles E, Barrellier MT, Becker F, Desprairies G, Guenneguez H, Mismetti P, Décousus H (2012). "Superficial venous thrombosis and compression ultrasound imaging". J. Vasc. Surg. 56 (4): 1032–8.e1. doi:10.1016/j.jvs.2012.03.014. PMID 22832262.
- ↑ Ellis MH, Fajer S (2013). "A current approach to superficial vein thrombosis". Eur. J. Haematol. 90 (2): 85–8. doi:10.1111/ejh.12044. PMID 23181477.
- ↑ 38.0 38.1 Blättler W, Schwarzenbach B, Largiadèr J (2008). "Superficial vein thrombophlebitis--serious concern or much ado about little?". VASA. 37 (1): 31–8. doi:10.1024/0301-1526.37.1.31. PMID 18512540.
- ↑ Di Nisio, M.; Wichers, IM.; Middeldorp, S. (2013). "Treatment for superficial thrombophlebitis of the leg". Cochrane Database Syst Rev. 4: CD004982. doi:10.1002/14651858.CD004982.pub5. PMID 23633322.
- ↑ "A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis". Arch Intern Med. 163 (14): 1657–63. 2003. doi:10.1001/archinte.163.14.1657. PMID 12885680. Unknown parameter
|month=ignored (help) - ↑ 41.0 41.1 41.2 Wichers IM, Di Nisio M, Büller HR, Middeldorp S (2005). "Treatment of superficial vein thrombosis to prevent deep vein thrombosis and pulmonary embolism: a systematic review". Haematologica. 90 (5): 672–7. PMID 15921382.
- ↑ Rathbun SW, Aston CE, Whitsett TL (2012). "A randomized trial of dalteparin compared with ibuprofen for the treatment of superficial thrombophlebitis". J Thromb Haemost. 10 (5): 833–9. doi:10.1111/j.1538-7836.2012.04669.x. PMC 3343207. PMID 22360152.