Superficial thrombophlebitis of the lower extremity

Superficial phlebitis refers to the clinical findings of pain, tenderness, induration, and erythema along the course of a superficial vein

Treatment is aimed at relieving local symptoms, but also the prevention of thromboembolic complications.

A source of ongoing confusion, and a dangerous and potentially lethal misnomer, is the persistent use of the abandoned term "superficial” femoral vein to describe the main deep vein in the thigh, properly called the femoral vein, which is adjacent to the superficial femoral artery . A need for a change in terminology was recognized when it became apparent that a majority of primary care physicians would not have treated a patient with a "superficial” femoral vein thrombosis with anticoagulation .

INCIDENCE — Lower extremity superficial phlebitis is relatively common with an incidence that is estimated to be between 3 and 11 percent in the general population . Phlebitis involves the great saphenous vein more commonly than the small saphenous vein

Venous stasis — Venous stasis increases the risk of superficial vein thrombosis

Although superficial thrombophlebitis is more likely to occur in varicose veins, non-varicose veins are affected in 5 to 10 percent of patients

Conversely, a history of superficial vein thrombosis increases the risk for future deep vein thrombosis.

Vein excision/ablation — Superficial phlebitis can develop following surgical, chemical or endovenous ablation of incompetent veins. Following vein excision, the residual end of an avulsed vein segment undergoes spasm and thrombosis.

Following endovenous ablation (ie, radiofrequency ablation, endovenous laser ablation), closure of the treated vein segment necessarily leads to thrombosis, termed endovenous heat-induced thrombosis (EHIT).

Radiofrequency ablation is associated with a lower incidence of clinically significant phlebitis compared with laser ablation; some newer laser wavelengths may cause less of a reaction.

MALIGNANCY AND HYPERCOAGULABLE STATES — Superficial phlebitis is associated with malignancy, hypercoagulable states, and thromboangiitis obliterans (ie, Buerger's disease).

Buerger's disease is a segmental inflammatory disease affecting the small and medium-sized arteries and veins in the distal extremities, often presenting in its early stages as a superficial phlebitis.

Catheter-related — Superficial phlebitis is frequently associated with peripheral or central venous catheter use due to a combination of endothelial injury and venous stasis. The upper extremity veins are affected far more commonly than lower extremity veins due to the frequency with which the upper extremity is used for access compared with the lower extremity.

IMPORTANT CLINICAL CONSIDERATIONS — A high index of suspicion for DVT or suppurative thrombophlebitis should be maintained whenever the diagnosis of superficial phlebitis is entertained. Pulmonary embolism has been reported, but is a rare complication of superficial phlebitis; however, embolization does not usually occur in the absence of deep vein involvement

If suppurative thrombophlebitis is suspected, antibiotic treatment, surgical drainage and potentially vein excision are indicated

Venous thromboembolism — Patients with pain and tenderness along the known course of a superficial vein with or without obvious physical findings (ie, erythema, palpable cord) likely have superficial phlebitis, but may potentially also have a DVT . Given their common risk factors, the association of superficial and DVT is not surprising.

SUMMARY AND RECOMMENDATIONS

The risk of superficial phlebitis is increased in patients with abnormal coagulation or fibrinolysis, endothelial dysfunction, infection, venous stasis, intravenous therapy, or intravenous drug abuse.

For patients with lower extremity superficial phlebitis affecting the saphenous vein (great or small), we suggest ultrasound upon initial presentation to rule out the presence of coexistent deep vein thrombosis (DVT). Duplex ultrasound should also be performed if there is evidence of clinical extension of phlebitis, lower extremity swelling that is greater than would be expected from the phlebitis alone, or the diagnosis of superficial phlebitis is in question

Risk factors for extension of thrombus into the deep venous system include more extensive superficial vein thrombosis ≥5 cm, anatomic proximity of thrombus to the deep venous system (≤5 cm) and medical risk factors for DVT (eg, prior DVT, thrombophilia, malignancy, estrogen therapy).

For patients with saphenous thrombus extending up to but not into the common femoral vein following radiofrequency or laser vein ablation, we suggest not routinely anticoagulating the patient (Grade 2C). These patients are not at high risk for DVT and are managed initially with supportive care and serial duplex ultrasound.

A decision to anticoagulate the patient when thrombus approaches the deep venous system at other sites (ie, saphenopopliteal junction, perforator veins) should be individualized; either anticoagulation or serial duplex ultrasound may be appropriate.