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| Question | Answer |
| 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 | Superficial phlebitis is generally a benign, self-limited disorder; however, it can be complicated by deep vein thrombosis (DVT) and even pulmonary embolism . |
| Treatment is aimed at relieving local symptoms, but also the prevention of thromboembolic complications. | TERMINOLOGY — The term phlebitis refers to the presence of inflammation within a vein, whereas thrombosis indicates the presence of clot. The term thrombophlebitis is used broadly in the literature and often refers to venous inflammation even when it is unclear whether thrombosis of the vein has occurred. |
| 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 . | Superficial phlebitis can occur as an isolated event or may be recurrent in the same vein. In some patients distinctly different vein segments can be affected over time and is referred to as migratory phlebitis. |
| 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 | RISK FACTORS — Lower extremity superficial phlebitis is associated with conditions that increase the risk of thrombosis, including abnormalities of coagulation or fibrinolysis, endothelial dysfunction, infection, venous stasis, intravenous therapy, and intravenous drug abuse. |
| Venous stasis — Venous stasis increases the risk of superficial vein thrombosis | Venous stasis can be due to acute venous disease (eg, DVT, venous trauma), chronic venous disease (eg, varicose veins, chronic venous insufficiency), venous procedures (eg, sclerotherapy, surgical ablation), immobilization (eg, postoperative, trauma), pregnancy, or obesity. |
| Although superficial thrombophlebitis is more likely to occur in varicose veins, non-varicose veins are affected in 5 to 10 percent of patients | Both a history of prior DVT as well as current DVT increase the risk for superficial vein thrombosis |
| Conversely, a history of superficial vein thrombosis increases the risk for future deep vein thrombosis. | In a study using data from the multiple environmental and genetic assessment of risk factors for venous thrombosis (MEGA) study, patients with a remote history of superficial vein thrombosis had an increased risk of developing deep vein thrombosis (odds ratio and pulmonary embolism , but thrombophilia was only weakly associated with superficial thrombophlebitis, implicating stasis from varicose veins and obesity as more important factors . |
| 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. | Thrombus may extend retrograde into an adjacent patent vein. |
| 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). | The phlebitis associated with endovenous procedures is due to injury not only to the endothelial surface of the vein, but also the media and adventitia. Varying degrees of pain and inflammation occur depending upon the device used to effect closure. |
| 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. | PREGNANCY AND ESTROGEN THERAPY — The incidence of phlebitis in the first month postpartum is significantly increased . The use of estrogen-progestin contraceptives and estrogen therapy also increase risk for both superficial phlebitis and venous thromboembolism. |
| MALIGNANCY AND HYPERCOAGULABLE STATES — Superficial phlebitis is associated with malignancy, hypercoagulable states, and thromboangiitis obliterans (ie, Buerger's disease). | In one study, risk factors were identified in 62 percent of patients with superficial phlebitis in non-varicose veins including thrombophilia (20 out of 42 patients), malignancy (2 out of 42 patients) and other nonmalignant systemic disease (4 out of 42 patients) . |
| 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. | Trousseau's syndrome of recurrent migratory phlebitis is associated with adenocarcinomas, particularly pancreatic cancer. |
| 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. | CLINICAL FEATURES AND DIAGNOSIS — Findings of tenderness, induration, pain and/or erythema along the course of a superficial vein usually establish a clinical diagnosis, especially in patients with known risk factors. In addition, there is often a palpable, sometimes nodular cord, due to thrombus within the affected vein. Persistence of this cord when the extremity is raised suggests the presence of thrombus. Some patients present with symptoms consistent with superficial phlebitis but have minimal physical findings due to body habitus. |
| 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 | IMPORTANT CLINICAL CONSIDERATIONS — suppurative thrombophlebitis — Low-grade fever may occur in uncomplicated superficial phlebitis, but high fever, fluctuance and/or purulent drainage suggest infection (ie, septic thrombophlebitis). Suppurative thrombophlebitis is suspected when erythema extends significantly beyond the margin of the vein and is likely to be associated with significant fever. |
| If suppurative thrombophlebitis is suspected, antibiotic treatment, surgical drainage and potentially vein excision are indicated | Septic thrombophlebitis is uncommon in the absence of a history of direct vascular injury such as venipuncture or catheterization |
| 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. | The risk for venous thromboembolism is the highest immediately following a diagnosis of superficial venous thrombosis, but persists over time. he risk was significantly increased and highest in the first three months , decreasing but still significantly higher after five years . |
| SUMMARY AND RECOMMENDATIONS | Superficial phlebitis is primarily a clinical diagnosis, based upon findings of pain, tenderness, induration, and/or erythema along the course of a superficial vein. |
| 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. | Patients should undergo repeat physical examination within 7 to 10 days of their initial diagnosis to look for resolution or progression. Any worsening of clinical symptoms or extension of signs of phlebitis on physical examination should prompt duplex ultrasound |
| 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 | For all patients diagnosed with superficial phlebitis, supportive measures should be instituted and consist of extremity elevation, warm or cool compresses, compression stockings, and pain management. |
| 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 lower extremity superficial thrombophlebitis at low risk for DVT (ie, affected venous segment <5 cm, remote from saphenofemoral/saphenopopliteal junction, no medical risk factors), we suggest oral nonsteroidal antiinflammatory drugs (NSAIDs) rather than anticoagulation as first-line drug 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. | For patients with superficial phlebitis (not related to endovenous ablation therapy) at increased risk for DVT (affected venous segment ≥5 cm, in proximity to the deep venous system (≤5 cm), positive medical risk factors), we suggest anticoagulation for four weeks over supportive care (ie, nonsteroidal antiinflammatory drugs and compression stockings) alone (Grade 2B). Fondaparinux, low molecular weight heparin, unfractionated heparin, and vitamin K antagonists are equally effective. |
| 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. | For thrombus extending into the deep venous system, the patient is treated according to standard protocols for DVT. |
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