AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Superficial vein thrombophlebitis may occur spontaneously or as a complication of medical or surgical interventions. Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult deep vein thrombosis (DVT), which carries very high rates of morbidity and mortality.

Superficial phlebitis with infection, such as phlebitis originating at an intravenous catheter site, is referred to as septic thrombophlebitis. This clinical entity requires special diagnostic and therapeutic approaches that are different from those applicable to sterile phlebitis. Septic thrombophlebitis is discussed in a separate article (see Thrombophlebitis, Septic).

Phlebitis should be assumed to involve the deep veins until proven otherwise, because superficial vein thrombophlebitis and deep vein thrombophlebitis share the same pathophysiology, pathogenesis, and risk factors.

Superficial thrombophlebitis often progresses through perforating veins to involve the adjacent deep veins. In the case of spontaneous thrombophlebitis, a superficial phlebitis at one location may be accompanied by occult deep vein thrombosis in noncontiguous veins in the same leg or even in the contralateral leg. This occurs because hypercoagulable states tend to produce thrombosis simultaneously at multiple sites in both the superficial and deep venous systems. A surprising number of patients with clinically apparent superficial phlebitis subsequently die from a pulmonary embolism (PE). Autopsy studies in these patients have demonstrated that the site of deep vein thrombosis often is not contiguous with the site of superficial phlebitis.

Clinical examination alone cannot distinguish purely superficial thrombophlebitis from phlebitis that has both superficial and deep vein components. When superficial and deep vein thrombosis coexist, the superficial veins usually are tender and inflamed, while the deep component most often is clinically silent. Duplex ultrasound identifies deep vein thrombosis in approximately 30% of patients with obvious superficial thrombophlebitis who have no clinical evidence of deep system involvement, and continued surveillance reveals occult deep vein extension in 45% of cases. In hospitalized patients with superficial phlebitis, 10% eventually have a recognized diagnosis of PE, and 20% of those PEs are fatal.

Studies purporting to show a lower incidence of DVT or PE in patients with clinically recognized superficial phlebitis should be reviewed with care; lower incidences commonly are reported in retrospective or follow-up studies where no criterion standard test was performed, since most cases of DVT and PE are not clinically recognized.

Every effort should be made to prevent superficial phlebitis from progressing to involve the deep veins, because damage to deep vein valves leads to chronic deep venous insufficiency (often referred to as postphlebitic syndrome) as well as to recurrent PE and a risk of death.

Pathophysiology

Microscopic thrombosis is a normal part of the dynamic balance of hemostasis. In 1846, the great German pathologist Virchow recognized that if this dynamic balance is altered by venous stasis, abnormal coagulability, or vessel wall injuries, microthrombi may propagate to form macroscopic thrombi.

In the absence of a triggering event, neither venous stasis nor abnormal coagulability alone causes clinically important thrombosis, but vascular endothelial injury does reliably cause thrombus formation. The initiating injury triggers an inflammatory response that results in immediate platelet adhesion at the site of injury. Further platelet aggregation is mediated by thromboxane A2 and by thrombin. Platelet aggregation due to thromboxane A2 is inhibited reversibly by nonsteroidal anti-inflammatory agents and irreversibly by aspirin, but thrombin-mediated platelet aggregation is unaffected by aspirin and nonsteroidals. This is why aspirin and nonsteroidal anti-inflammatories are somewhat effective in preventing arterial thrombosis, including stroke and myocardial infarction, but they are not very effective in preventing or treating venous thrombophlebitis.

Frequency

United States

Superficial thrombophlebitis is so common and so often ignored that obtaining valid estimates of its frequency is very difficult. Purely superficial thrombophlebitis often appears clinically obvious, but the clinical diagnosis of thrombophlebitis is accurate only 50% of the time, even if the patient has classical symptoms.

One third of patients in a medical intensive care unit develop thrombophlebitis that eventually progresses to the deep veins. Approximately 40% of patients admitted and placed on bedrest for acute myocardial infarction develop superficial phlebitis that progresses to DVT. The lifetime incidence of superficial thrombophlebitis in patients with untreated varicose veins has been estimated at 20-50%, with unrecognized associated deep vein thrombosis in up to 45% of patients. This appears to be the mechanism responsible for a 3-fold increased incidence of DVT in patients with superficial varicosities.

The true incidence of DVT (with or without associated superficial thrombophlebitis) is also unknown. The incidence has been estimated as approximately 3 million cases per year, but this number cannot be considered reliable.

Mortality/Morbidity

Adverse outcomes from thrombophlebitis are common, particularly when the process extends to involve the deep venous system.

• Recanalization of thrombosed veins results in a valveless channel, leading to a prolonged venous circulation time and often to chronically elevated ambulatory venous pressure within the legs. Elevated venous pressures and delayed clearance of venous blood from the legs produces a clinical postphlebitic syndrome of chronic pain, edema, hyperpigmentation, ulceration, and a high risk of recurrent thrombophlebitis and PE.
• Valvular damage from phlebitis is equally important at any level in the leg. Isolated calf vein thrombophlebitis results in clinical postphlebitic syndrome in 20-40% of cases. Valvular incompetence isolated to popliteal venous segments produces signs and symptoms of severe chronic venous insufficiency in more than 60% of cases, with elevated ambulatory venous pressures averaging 72 mm Hg.
• In the Framingham study population, PE was an autopsy-proven principal or contributing cause of death in 16% of cases. Other autopsy studies have revealed evidence of prior venous thrombosis in up to 60% of all patients who undergo autopsy.

Sex

• Pregnancy and the puerperium are recognized risk factors for phlebitis. High-dose estrogen therapy is also a risk factor, but no intrinsic sex-linked preferential risk exists for the disease.
• The likelihood of thrombophlebitis is increased through most of pregnancy and for approximately 6 weeks after delivery. This is partly due to increased platelet stickiness and partly due to reduced fibrinolytic activity.
• Case-controlled and cohort studies based on clinical signs and symptoms of thrombosis suggest that, by taking high-estrogen oral contraceptives, a woman may increase her risk of thrombosis by a factor of 3-12 times, although the absolute risk remains low. Newer low-dose oral contraceptives are associated with a much lower risk of thrombophlebitis, although the absolute risk has not been well quantified.

Age

Age is not an independent risk factor for phlebitis, but the incidence of other recognized risk factors increases with age, leading to an overall increased risk with increasing age.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Patients with superficial thrombophlebitis often give a history of a gradual onset of localized tenderness, followed by the appearance of an area of erythema along the path of a superficial vein. There may be a history of local trauma, prior similar episodes, varicose veins, prolonged travel, or enforced stasis. The patient should be asked about risk factors for hypercoagulability, but the absence of identifiable risk factors has no prognostic value.
• Occasionally, a spurious history of sudden onset of pain is given. A true sudden onset of pain suggests some other etiology for the symptoms. Similarly, patients occasionally report the recent sudden development of venous ulcers, stasis changes, and other conditions that, upon inspection, obviously have been present for many months or years.

Physical

• Inspection: Visual appearance is not a reliable guide to peripheral venous condition, because the clinical findings of venous disease are common to many other entities. Swelling may result from acute venous obstruction (as in deep vein thrombosis) or from deep or superficial venous reflux, or it may be caused by an unrelated disease condition such as hepatic insufficiency, renal failure, cardiac decompensation, infection, trauma, or environmental effects. Lymphedema may be primary or it may be secondary to overproduction of lymph due to severe venous hypertension.
• • Normal veins are distended visibly at the foot, ankle, and occasionally in the popliteal fossa, but not in the rest of the leg. Normal veins may be visible as a blue subdermal reticular pattern, but dilated superficial leg veins above the ankle usually are evidence of venous pathology.
  • Darkened, discolored, stained skin or nonhealing ulcers are typical signs of chronic venous stasis, particularly along the medial ankle and the medial lower leg. Chronic varicosities or telangiectasias also may be observed.
  • Acute deep venous obstruction may cause the sudden appearance of new vessels, large or small, that have become dilated to serve as a bypass pathway. New varices and telangiectasias often appear during pregnancy, principally due to hormonal changes that make the vein wall and valves more pliable. Although hormonally mediated varicosities of pregnancy are common, the sudden appearance of dilated varicosities during pregnancy still warrants evaluation for acute deep vein thrombosis, which is also common in pregnancy.
• Palpation: Palpation of a painful or tender area may reveal a firm, thickened, thrombosed vein. Palpable thrombosed vessels are virtually always superficial, but combined deep and superficial venous thrombosis is very common.
• • A thrombosed popliteal vein sometimes may be palpated in the popliteal fossa and a thrombosed common femoral vein sometimes may be palpated at the groin. These must not be mistaken for superficial vessels.
  • Palpation helps to distinguish varices of recent onset from chronic varices. New varices lie on the surface of the underlying tissue, but chronically dilated vessels erode channels into underlying muscle or bone, creating deep boggy pockets in calf muscle and palpable notches in the bone of the anterior tibia.
  • If the patient is kept standing for a few minutes, palpation reveals other superficial veins that cannot be seen. The greater saphenous vein becomes palpable in most patients after a few minutes of standing, but other normal superficial veins above the foot cannot be detected by palpation, even after prolonged standing.
  • Palpation also may reveal fascial defects along the course of a varicosity. These defects are sites through which perforating veins may pass, carrying blood between the superficial and deep venous systems. Arteries and nerves often accompany perforating veins as they pass through these fascial defects.
• Percussion: Perthes percussive test is a classic maneuver that is useful to test whether venous segments are interconnected. With the patient in a standing position, a vein segment is tapped at one location while an examining hand feels for a pulse wave at another location. Propagation of a palpable pulse wave suggests that a fluid-filled vessel with open or incompetent valves connects the two locations.
• • A pulse wave may be propagated after prolonged standing in the absence of true pathology, because prolonged standing causes even normal veins to become distended and normal valves to float open.
  • Perthes test is most valuable when a bulging varicosity in the lower leg has no obvious connection with a varicosity in the upper thigh. A palpable pulse wave propagation between the two vessels is proof positive of the existence of an unseen connection.
• Trendelenburg test: The Trendelenburg test is a classic physical examination maneuver that helps to distinguish superficial venous reflux from incompetence of the deep vein valves.
• • The leg is elevated until all superficial veins have collapsed, and the point of suspected reflux from the deep system is occluded by manual compression or by a tourniquet. The patient is then asked to stand, and the distal varicosity is observed for refilling. If the distal varicosity remains mostly empty, the reflux pathway is principally through the peripheral varicosity that has been occluded.
  • Inability to prevent rapid filling of the varicosity despite manual occlusion of the suspected high point of reflux suggests that another reflux pathway is involved.
  • Rapid refilling of calf varices despite occlusion of the proximal trunk suggests deep system reflux or failure of the valves of multiple perforating veins.

Causes

The most important clinically identifiable risk factors for thrombophlebitis are a prior history of superficial phlebitis, deep vein thrombosis, or pulmonary embolism. Other extremely common risk markers include recent surgery or pregnancy, prolonged immobilization, or underlying malignancy. Other recognized markers of risk for venous thromboembolic disease are listed here.

• AIDS (lupus anticoagulant)
• Antithrombin III deficiency
• Behçet disease
• Blood type A
• Burns
• Catheters (indwelling venous infusion catheters)
• Chemotherapy
• Congestive heart failure
• Drug abuse (intravenous [IV] drugs)
• Drug-induced lupus anticoagulant
• DVT in the past
• Estrogen replacements (high dose only)
• Fibrinogen abnormality
• Fractures
• Hemolytic anemias
• Heparin-associated thrombocytopenia
• Homocysteinemia
• Homocystinuria
• Hyperlipidemias
• Immobilization
• Malignancy
• Myocardial infarction
• Obesity
• Old age
• Oral contraceptives
• PE in the past
• Phenothiazines
• Plasminogen abnormality
• Plasminogen activator abnormality
• Polycythemia
• Postoperative
• Postpartum period
• Pregnancy
• Protein C deficiency
• Protein S deficiency
• Resistance to activated protein C
• Systemic lupus erythematosus
• Thrombocytosis
• Trauma
• Ulcerative colitis
• Varicose veins
• Venography
• Venous pacemakers
• Venous stasis
• Warfarin (first few days of therapy)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

The clinical diagnosis of superficial phlebitis is moderately reliable, but the key question of whether the deep system is involved simply cannot be answered without definitive testing. Many other problems can masquerade as thrombophlebitis of the deep and superficial systems, including the following:

Baker cyst
Chronic venous insufficiency
Hematomata
Lipodermatosclerosis
Lymphangitis
Lymphedema
Neuritis
Postphlebitic syndrome
Ruptured medial head of the gastrocnemius
Soft-tissue injury
Varicosities

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Blood tests rarely are helpful in the diagnosis of sterile venous thrombophlebitis, but they can be very helpful in identifying risk factors for further progression or recurrence in patients who do have superficial or deep phlebitis.
• • The prothrombin time (PT) and activated partial thromboplastin time (aPTT) are not useful in the diagnostic evaluation of patients with suspected superficial or deep thrombophlebitis. Most patients with thrombophlebitis have a normal PT and aPTT, and active thrombophlebitis is not uncommon in patients with a therapeutically elevated INR due to warfarin therapy.
  • A low white blood cell (WBC) count lowers the likelihood of an infectious process and raises the likelihood of phlebitis. An elevated WBC count is nonspecific because both normal and elevated WBC counts are common in patients with thrombophlebitis. Chronic venous insufficiency (venous congestion due to reflux) and superficial or deep vein thrombosis can mimic leg cellulitis very closely, and true cellulitis (with an elevated WBC count) is a frequent complication of both diseases.
• D-dimer is a unique degradation product produced by plasmin-mediated proteolysis of cross-linked fibrin. D-dimer is measured by latex agglutination or by an enzyme-linked immunosorbent assay (ELISA) test whose result is considered positive if the level is greater than 500 ng/mL.
• • At the present time, a positive D-dimer is an indication for further investigation, but a negative D-dimer is not reliably sensitive enough to change the course of diagnostic evaluation or treatment for patients with suspected superficial or deep thrombophlebitis or PE. Complex theoretical algorithms that attempt to combine unreliable D-dimer results with unreliable guesses at clinical likelihood are not useful in guiding the workup of a live patient with signs or symptoms suggestive of DVT or PE.
  • The latex agglutination test (various trade names) is completely unreliable, with a sensitivity of only 50-60% for DVT and PE.
  • The ELISA test is more sensitive than the latex agglutination test, but in a population with a PE prevalence of 50%, the negative predictive value of the test is still only 79%. In good studies, the D-dimer study misses 10% of the patients with positive pulmonary angiograms, while only 30% of those with a positive D-dimer have a positive angiogram.
• Several common hypercoagulable states can be identified through laboratory studies. These tests should be ordered for every patient with phlebitis. They can have a profound impact on the short-term and long-term treatment plan and the frequency of follow-up examinations.
• • Resistance to activated protein C (most often due to factor V Leyden)
  • Protein C deficiency
  • Protein S deficiency
  • Antithrombin III deficiency
  • Antiphospholipid antibodies
  • Lupus anticoagulant

Imaging Studies

• Proper diagnosis of venous system disease often requires both functional and anatomic information about the venous circulation.
• • The functional tests (discussed below) are extremely useful as measures of whole-leg or regional venous function, but functional tests can detect only regionally significant reflux or a significant impediment to venous outflow.
  • Anatomic imaging of the venous system can detect small amounts of local and regional reflux as well as obstructing and nonobstructing thrombus. Unfortunately, anatomic imaging often fails to identify important functional deficits.
  • A combination of functional and semi-anatomic or anatomic techniques allows a complete understanding of most venous system pathology.
• All patients with sterile superficial phlebitis must undergo a complete workup including an anatomic imaging test to rule out DVT, because determining from clinical examination whether the process has spread to involve the deep veins is impossible. The diagnostic evaluation of patients with potential septic thrombophlebitis, such as phlebitis associated with an intravenous catheter site, is discussed in the article Thrombophlebitis, Septic.
• • Successful anatomic imaging of the deep venous system requires a thorough knowledge of venous anatomy and physiology and a meticulous attention to detail.
  • Anatomic imaging is performed using contrast venography, B-mode ultrasound, or MRI to produce an actual picture of the deep vessels and their contents.
  • Venous imaging can reveal thrombi that are functionally silent, such as small, nonobstructing mural thrombi and free-floating thrombi that do not disturb flow significantly. Venous imaging also can identify thrombus that occludes venous collaterals or accessory veins but does not produce a functional alteration of regional flow because it poses no major impediment to venous outflow.
• Duplex ultrasound is the initial diagnostic study of choice for most patients with signs and symptoms of phlebitis. When phlebitis reflects an underlying hypercoagulable state, superficial phlebitis in one area may accompany deep vein thrombosis in another area or even in the other leg. For this reason, duplex examination should not be limited to just one leg or to just one area of one leg.
• • Unfortunately, duplex ultrasound is not perfectly sensitive, and it fails to detect DVT in many patients who are ultimately proven to have had a DVT.
  • After DVT has been excluded by ultrasound examination, patients with superficial phlebitis should be monitored carefully with serial examinations until the phlebitis is resolved. Disease that initially involves only the superficial veins may progress over time to involve the deep system.
  • A negative duplex ultrasound scan is reassuring, but it is not a guarantee of a good outcome. Duplex ultrasound is not 100% sensitive for deep vein thrombosis, and even when DVT is truly absent, purely superficial thrombophlebitis can embolize to the lungs in some cases.
  • Because ultrasound can miss DVT, all patients with superficial phlebitis who also have chest symptoms (such as pain, shortness of breath, or cough) should have a chest x-ray and ventilation-perfusion (V/Q) scan or high-resolution contrast CT scan of the chest, even if a duplex examination fails to reveal deep vein thrombosis.
• Magnetic resonance venography (MRV) is a noninvasive test that probably is more sensitive and more specific than ultrasound in the detection of deep venous thrombophlebitis.
• • Unfortunately, MRV is not readily available at many institutions, and many radiologists are inexperienced in the reading of MRV studies.
  • MRV has a great advantage in the assessment of symptoms attributed to venous disease, because it can reveal an alternate diagnosis in 60% of the cases in which primary venous disease is not the culprit.
• Invasive contrast venography has long been the criterion standard for evaluation of the venous system, but it has fallen into disuse in many institutions. The procedure is time-consuming, involves ionizing radiation, and carries a risk of anaphylactoid reactions to IV contrast.
• • As many as 16% of patients reportedly develop new DVT after venography, but careful review suggests that most of these reports actually represented missed thromboses that simply continued to grow after being missed.
  • Contrast venography has recently begun to enjoy a renaissance, largely because it is now used to guide direct transcatheter infusion of fibrinolytic agents in an increasing number of patients with deep venous thrombosis.
• Where definitive testing is not immediately available, the patient should be presumed to have deep system involvement and should be fully anticoagulated immediately while awaiting a definitive test result.

Other Tests

• Physiologic tests of venous function are when used to assess venous function in both the deep and the superficial venous systems, but they are of secondary importance in patients with active phlebitis. These tests can sometimes detect deep system thrombophlebitis, but only when significant obstruction to outflow has produced significant venous congestion.
• • The criterion standard for functional testing of the lower extremity venous system is invasive ambulatory venous pressure (AVP) monitoring. The AVP is measured by placing a catheter into a dorsal foot vein or a vein of the lower leg and recording the venous pressure while the patient ambulates and performs other maneuvers.
  • The most common noninvasive tests are impedance plethysmography, photoplethysmography (including light reflection rheography and digital techniques), and pneumoplethysmography (including quantitative air plethysmography). All of these tests address the same physiologic functional measures.
  • In each type of functional testing, venous pressure changes are recorded while the patient walks or raises up on tiptoe or performs ankle dorsiflexions. The recorded pressure tracings reflect the functional condition of the venous system.
  • In a normal leg, each pumping cycle lowers the pressure as blood is pumped inward and upward. Six cycles are usually sufficient to achieve a maximal reduction in pressure. The pressure normally rises again slowly as the leg is refilled, reaching a maximum within 3-5 minutes.
  • The physiologic parameters that are measured include the maximum venous outflow (MVO), calf muscle pump expulsion fraction (MPEF), and venous refilling time (VRT) of the extremity.
  • The MVO and MPEF are decreased when the deep veins are occluded significantly. The MPEF also is decreased when primary failure of the calf muscle pump mechanism occurs. The VRT is shortened when valvular damage in the deep or superficial veins allows venous blood to reflux downward into the extremity.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

The critical role of the emergency department is to make the correct diagnosis of superficial versus deep thrombophlebitis based not on guesswork but on objective diagnostic testing.

If diagnostic tests show that the deep system is not involved, a rational approach to the initial treatment of superficial phlebitis can be based upon the patient's history and risk factors, together with the results of a detailed ultrasound examination.

Recognized causes of venous stasis such as air travel or extended bedrest are strongly contraindicated in all patients with phlebitis of any type.

• Medications
  • Nonsteroidal anti-inflammatory agents are useful in reducing pain and in limiting the contribution of local inflammation.
  • Anticoagulation with heparin is useful in preventing the progression of thrombosis.
  • Local fibrinolysis is useful when the deep system is involved or threatened, as well as when preserving the patency of a superficial vessel is important.
• Increased ambulation is important to avoid venous stasis that can contribute to the progression of thrombosis.
• Compression stockings
  • Gradient compression stockings are an often-overlooked adjunctive therapy that is both benign and effective. Gradient compression hose are highly elastic stockings providing a gradient of compression that is highest at the toes (at least 30 to 40 mm Hg) and gradually decreases to the level of the thigh. This amount of compression reduces capacitive venous volume by approximately 70% and increases the measured velocity of blood flow in the deep veins by a factor of 5 or more. Gradient compression hose also have been shown to increase local and regional intrinsic fibrinolytic activity.
  • Compression stockings of this type have been proven effective in the prophylaxis of thromboembolism and are also effective in preventing progression of thrombus in patients who already have superficial phlebitis or actual DVT and PE.
  • A 1994 meta-analysis calculated a DVT odds ratio of 0.28 for gradient compression stockings (as compared to no prophylaxis) in patients undergoing abdominal surgery, gynecologic surgery, or neurosurgery. Other studies have found that gradient compression stockings and low-molecular-weight heparin were the most effective modalities in reducing the incidence of deep vein thrombosis after hip surgery and were far more effective than subcutaneous unfractionated heparin, oral warfarin, dextran, or aspirin.
  • Gradient compression pantyhose (30 to 40 mm Hg) are available in pregnant sizes and are recommended by many specialists for all pregnant women because they not only prevent DVT, but they reduce or prevent the development of varicose veins and the incidence of superficial phlebitis during this period.
  • The ubiquitous white stockings known as anti-embolic stockings (Ted hose) produce a maximum compression of only 18 mm Hg. This is too low to have any effect on deep venous flow dynamics. They are of no real efficacy in the treatment of superficial or deep phlebitis and have not been shown effective as prophylaxis against thromboembolism.
• The most easily treated patients are those with superficial phlebitis not involving the greater saphenous vein above the knee, without known risk factors and with no prior thromboembolic history. Such patients most often respond to the combination of nonsteroidal anti-inflammatory agents, gradient compression hose, increased ambulation, and early repeat examination.
• More aggressive treatment is indicated for patients who have a prior history of deep thrombophlebitis, for those with known irreversible risk factors for venous thrombosis, and for those with decreased mobility.
• • These patients are treated as outpatients with full-dose anticoagulation using subcutaneous low-molecular-weight heparin (LMWH).
  • Nonsteroidal anti-inflammatory agents, gradient compression hose, increased ambulation, and early repeat examination are also essential.
  • Antibiotics should be used in any patients in whom the phlebitis may be septic.
• The most aggressive treatment is necessary for patients with superficial phlebitis involving the greater saphenous vein above the knee, because greater saphenous phlebitis often ascends to pass through the saphenofemoral junction at the groin and into the deep venous system.
• • These patients are treated as outpatients with full-dose anticoagulation using subcutaneous LMWH.
  • Antibiotics should be used whenever the phlebitis involves the proximal thigh.
  • Nonsteroidal anti-inflammatory agents, gradient compression hose, increased ambulation, and early repeat examination are also essential.
• A painful section of a superficial vein containing a palpable intravascular coagulum may be treated by puncture incision and evacuation of the clot. This procedure often produces marked rapid relief and rapid resolution of the inflammation.
• • This simple procedure is carried out by puncturing the vessel with an 18-gauge needle and then aspirating or manually expressing the partially liquefied thrombus.
  • Because areas affected by superficial phlebitis can be very tender, local anesthesia may be helpful when drainage of coagulum is contemplated.
  • Puncture and evacuation is less effective in the first week after the onset of symptoms, because the vessel wall is thickened and the coagulum itself is more cohesive during the early phase of a phlebitis.
• Local transcatheter fibrinolytic therapy can arrest the progression of disease in most cases, and it is now the treatment of choice when greater saphenous phlebitis approaches the saphenofemoral junction.
• • In the past, surgical interruption of the saphenofemoral junction (with or without removal of the saphenous vein) was recommended for patients with greater saphenous phlebitis approaching the saphenofemoral junction. Enthusiasm for this approach has decreased since prospective studies have demonstrated nearly a 100% incidence of postoperative ileofemoral DVT following this procedure.
  • Local transcatheter fibrinolysis provides an important modern alternative to this older surgical approach.
• A special subgroup of patients includes those with superficial phlebitis in the lower leg that has passed into the deep system through calf perforators but involves only tiny saccular venous channels in the peroneal and soleal plexus.
• • Calf vein DVT involving the tibial veins or the proximal segment of the peroneal vein is a common cause of fatal PE, but calf DVT isolated to these small saccular intramuscular channels has no direct pathway for embolization of a long thrombus and is principally of concern because of the risk of progression into longer, straighter deep veins.
  • These patients with distal saccular DVT need especially close surveillance, but they often respond rapidly to an outpatient regimen of full-dose subcutaneous LMWH, compression hose, increased ambulation, and early repeat duplex ultrasound. Serial duplex ultrasound examinations should be performed every 24-72 hours (and immediately whenever new symptoms appear) until thrombus is seen to regress.
  • Fibrinolysis should be considered if deep system thrombosis is seen to progress despite full anticoagulation.
• Phlebitis that has progressed to involve any other deep veins (anterior or posterior tibial veins, proximal peroneal vein, popliteal vein or femoral vein at any level) is a serious and life-threatening condition that must not be confused with superficial venous thrombophlebitis.
  • Contrary to popular belief, tibial deep vein thrombophlebitis carries nearly the same risk of fatal PE as thrombus in the more proximal deep veins of the thighs.
  • Deep vein thrombophlebitis mandates immediate full-dose anticoagulation and an evaluation for possible occult PE (seen in 60% of asymptomatic patients). Strict gradient compression therapy is essential. Maintenance of ambulation is routine in Europe but only recently has begun to be adopted in the United States.
  • Patients with DVT always should be considered as potential candidates for transcatheter fibrinolytic therapy, which can reduce the incidence of chronic postphlebitic syndrome by at least 50% and also can reduce the risk of recurrence and of progression to PE.
• Special warning
  • The principal deep vein of the thigh often is referred to incorrectly as the "superficial femoral vein." Do not be misled by this nomenclature.
  • Many patients have died because clinicians mistakenly have treated thrombus in the superficial femoral vein as though it were a superficial phlebitis, when in fact it is the most serious type of DVT.

Consultations

• Duplex ultrasound may be performed by an emergency physician with training and experience in vascular ultrasound, but most often it is carried out in the vascular laboratory or the radiology department.
• • Duplex ultrasound should be performed by a highly motivated and experienced person, because the ultrasonographic signs of deep vein involvement are sometimes subtle and highly localized.
  • An inexperienced person is not able to perform an adequate ultrasound examination while referring to a textbook of normal and abnormal findings.
• In the fibrinolytic era, most institutions have an interventional radiologist who is prepared to perform transcatheter fibrinolysis of acute thrombus at nearly any site. Fibrinolysis for DVT is indicated whenever thrombus is seen to progress despite full anticoagulation, when a large floating thrombus threatens to embolize, and when embolus is seen within the right heart. Transcatheter fibrinolysis should be at least considered for every case of femoral-popliteal or ileofemoral DVT and for every case of greater saphenous thrombosis that approaches the saphenofemoral junction.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of therapy for superficial phlebitis are to prevent progression into the deep venous system and to hasten the resolution of the inflammatory and thrombotic processes in areas already involved.

Drug Category: Fibrinolytic agents

Fibrinolysis often is indicated for deep vein thrombophlebitis, but it is indicated only rarely for superficial phlebitis.

The principal indication for fibrinolysis in superficial phlebitis is greater saphenous phlebitis approaching the saphenofemoral junction at the groin.

A secondary indication is to prevent postthrombotic sclerosis and to preserve superficial vessels for use in dialysis and in other rare cases in which preserving an affected superficial vessel is highly desirable.

Catheter-directed local infusions of fibrinolytic agents are safer than systemic fibrinolytic regimens because they use a low dose of the drug and usually do not produce a systemic lytic state. Several fibrinolytic agents are currently available for local-regional lysis of thrombus.

Reteplase is a second-generation recombinant tissue-type plasminogen activator that seems to work more quickly and to have a lower bleeding risk than the first-generation agent (alteplase).

Alteplase is the first-generation recombinant tissue-type plasminogen activator. Alteplase is the fibrinolytic agent most familiar to emergency departments, and it is the lytic agent most often used for the treatment of coronary artery thrombosis, pulmonary embolism, and acute stroke.

Urokinase is the fibrinolytic agent most familiar to interventional radiologists, and the one that has most often been used for septic phlebitis. At the time of this writing, urokinase is not available from the manufacturer. Availability of urokinase in the immediate future is not known. In the meantime, the FDA has encouraged the off-label use of reteplase and alteplase for local-regional lysis of venous and arterial thrombus at any location.

Streptokinase is a less expensive alternative that, unfortunately, is highly antigenic and produces a high incidence of untoward reactions. This drawback limits the usefulness of streptokinase in the clinical setting.

Drug Category: Anticoagulants

Heparin is essential for patients with superficial thrombophlebitis that is progressive and for those with particular risk factors for progression or recurrence. Heparin should always be used when thrombophlebitis involves the greater saphenous vein. Heparin is the mainstay of treatment when deep system involvement is suggested, but anticoagulation alone does not guarantee a successful outcome. The disease may progress despite full and effective heparin anticoagulation.

Heparin works by activating antithrombin III to slow or prevent the progression of venous thrombosis. Heparin does not dissolve existing clot.

Fractionated LMWHs have largely replaced unfractionated heparin in the treatment of superficial phlebitis. LMWHs offer several distinct advantages over unfractionated heparin: they may be used in the outpatient setting, they do not require measurement of the aPTT, they produce more reliable anticoagulation, and they are associated with a lower risk of bleeding.

When unfractionated heparin is used, an aPTT of at least 1.5 times the control value is necessary for a therapeutic effect. To achieve this, unfractionated heparin must be given intravenously in adequate doses. Low-dose subcutaneous unfractionated heparin should not be used, as it is not an effective therapy for thrombophlebitis and it is not an effective prophylaxis against progression of the disease.

Warfarin should not be used in the acute treatment of superficial phlebitis, because the early risk of increased thrombogenesis outweighs any convenience of oral therapy.

Drug Category: Antibiotics

These agents are not routinely useful in nonseptic superficial phlebitis. Antibiotics are indicated whenever infection is suspected to play a role and whenever phlebitis of the greater saphenous vein above the knee threatens to approach the saphenofemoral junction. The choice of antibiotics should be guided by blood culture results whenever possible, but empiric therapy should at a minimum provide coverage for group A streptococci and for Staphylococcus aureus.

Superficial phlebitis must not be confused with septic phlebitis, which can be life threatening. If septic phlebitis is suspected, the selection of antibiotics is critically important and depends upon the clinical setting. Antibiotics for septic phlebitis are discussed in the article Thrombophlebitis, Septic.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Patient Education

• For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education articles Varicose Veins, Blood Clot in the Legs, and Phlebitis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Patients who present with clinical evidence of superficial phlebitis often have deep system involvement that is clinically occult. Those who lack deep system involvement often progress to develop DVT over time. The incidence of fatal PE in these patients is not insignificant. Any chest symptoms, no matter how minor, should be considered extremely worrisome in a patient with superficial thrombophlebitis.
• PE is extremely common, and some cases can be difficult to diagnose. Unfortunately, many patients with obvious PE that could be diagnosed easily still go unrecognized because of inadequate diagnostic evaluation in the ED. Respiratory problems and leg pain are the most common complaints in patients who are seen alive in the ED and later die unexpectedly.
• A small number of often-repeated mistakes in diagnosis and treatment are responsible for a large proportion of the bad outcomes with serious legal repercussions.
• • Failure to pursue a definitive workup, attempting instead to diagnose superficial thrombophlebitis and rule out DVT on clinical grounds that are known to be unreliable
  • Failure to warn the patient that superficial phlebitis can progress to the deep veins and that any change in symptoms warrants immediate re-evaluation
  • Failure to properly diagnose and treat DVT in patients whose symptoms include any degree of leg pain or objective or subjective edema
  • Failure to treat superficial phlebitis appropriately
  • Failure to recognize that DVT below the knee must be taken as seriously as more proximal DVT. The obsolete practice of dismissing calf vein thrombosis as though it were benign is absolutely wrong and has caused the death of many patients. This practice has resulted in lawsuits against many physicians, including prominent and knowledgeable leaders in the field.
  • Failure to order a V/Q scan when a patient has chest symptoms in the presence of leg symptoms
  • Failure to start anticoagulation immediately upon the diagnosis of DVT or at the first suspicion of PE (before the V/Q scan)

Special Concerns

• Venous thrombophlebitis and PE are common during all trimesters of pregnancy and for 6-12 weeks after delivery.
• Superficial varicosities and superficial phlebitis are common during pregnancy, and associated DVT is also common because of a pregnancy-related reduction in intrinsic plasminogen activator activity.
• • The diagnostic approach should be exactly the same in a pregnant patient as in a nonpregnant one.
  • Duplex scanning is safe in pregnancy.
  • If indicated, a nuclear perfusion lung scan may be performed safely in pregnancy.
  • If indicated, heparin may be used in pregnancy.
  • If indicated, fibrinolytics may be used in pregnancy.
  • Failure to treat the mother properly is the most common cause of fetal demise.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ascher E, Hanson JN, Salles-Cunha S, et al. Lesser saphenous vein thrombophlebitis: its natural history and implications for management. Vasc Endovascular Surg. Nov-Dec 2003;37(6):421-7. [Medline].
• De Maeseneer MG. Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment. Acta Chir Belg. Apr 2005;105(2):145-7. [Medline].
• Feied CF. Peripheral venous disease. In: Rosen P, Barkin RM, eds. Emergency Medicine Principles and Practice. 4th ed. Mosby-Year Book;1998:3.
• Feied CF. Pulmonary embolism. In: Rosen P, Barkin RM, eds. Emergency Medicine Principles and Practice. 4th ed. Mosby-Year Book;1998:3.
• Feied CF. Pulmonary chest pain, cor pulmonale and pulmonary embolism. In: Gibler, Aufderheide, eds. Emergency Cardiac Care. 1st ed. Vol 1. Mosby-Year Book;1994:243-303.
• Schonauer V, Kyrle PA, Weltermann A, et al. Superficial thrombophlebitis and risk for recurrent venous thromboembolism. J Vasc Surg. Apr 2003;37(4):834-8. [Medline].
• Unno N, Mitsuoka H, Uchiyama T, et al. Superficial thrombophlebitis of the lower limbs in patients with varicose veins. Surg Today. 2002;32(5):397-401. [Medline].
• de Godoy JM, Braile DM. Protein S deficiency in repetitive superficial thrombophlebitis. Clin Appl Thromb Hemost. Jan 2003;9(1):61-2. [Medline].

Article Last Updated: Feb 8, 2007