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Superficial Thrombophlebitis

Author: Nelson Menezes, MD, RVT, Chief of Vascular Surgery, Assistant Professor, Department of Surgery, Division of Vascular Surgery, The Brooklyn Hospital Center and Cornell University
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Updated: Feb 27, 2009

Introduction

Background

Thrombosis or thrombophlebitis of the superficial venous system receives little attention in textbooks of surgery and medicine. However, thrombophlebitis is encountered frequently and, at times, can cause significant incapacitation. It is usually a benign self-limiting disease, but it can be recurrent and tenaciously persistent. At times, when affecting the greater saphenous vein, thrombophlebitis can progress into the deep venous system, which may lead to pulmonary embolism.

Superficial thrombophlebitis is an inflammatory reaction with thrombus of a vein under the skin. Distinguishing venous thrombosis from venous phlebitis can be challenging. Deep vein thrombosis (phlebothrombosis) can be asymptomatic, which means that thrombosis of the vein can be present without phlebitis. However, most of the superficial veins that develop thrombosis also have phlebitis, thus the term thrombophlebitis. Also, phlebitis is usually associated with thrombosis and an inflammatory reaction involving the vein.

Pathophysiology

Although the etiology is frequently obscure, superficial venous thrombosis is most often associated with one of the components of the Virchow triad, ie, intimal damage (which can result from trauma, infection, or inflammation), stasis, or changes in the blood constituents (presumably causing changes in coagulability). Although superficial thrombophlebitis usually occurs in the lower extremities, it also has been described in the penis and the breast (Mondor disease). Superficial thrombophlebitis also occurs anywhere medical interventions occur, such as in the arm or neck (external jugular vein) from intravenous catheters.

Frequency

International

Superficial thrombophlebitis is a common condition worldwide.

Mortality/Morbidity

Death from superficial thrombophlebitis without complication is unusual; however, if superficial thrombophlebitis extends into the deep venous system, it can be the source of pulmonary emboli.

Sex

• McColl and associates charted a possible risk of thrombophilia as a result of pregnancy, which could lead to superficial thrombophlebitis.¹ This is of concern to those women who carry the factor V Leiden or prothrombin C-20210-a genes, in whom a predisposition towards clotting is present.
• Several studies indicate that oral contraceptives can increase the risk of thrombophlebitis. The risk of clotting is not well defined with more recent formulations of oral contraceptives with lower estrogen doses.

Age

• In the author's experience, superficial thrombophlebitis most frequently occurs in the age group ranging from young adults to middle-aged persons.
• However, Markovic and associates report that a common risk factor is age older than 60 years, but fewer complications occur in this age group.²

Clinical

History

Types of superficial venous thrombosis are as follows:

• Traumatic thrombophlebitis
  • Superficial venous thrombosis following an injury usually occurs in an extremity, manifesting as a tender cord along the course of a vein juxtaposing the area of trauma. Ecchymosis may be present early in the disease, indicating extravasation of blood associated with injury to the vein, and this may turn to brownish pigmentation over the vein as the inflammation resolves.
  • Thrombophlebitis frequently occurs at the site of an intravenous infusion and is the result of irritating drugs, hypertonic solutions, or the intraluminal catheter or cannula itself. This is by far the most common type of thrombophlebitis encountered. Usually, redness and pain signal its presence while the infusion is being given, but thrombosis may manifest as a small lump days or weeks after the infusion apparatus has been removed. It may take months to completely resolve.
  • The features of the iatrogenic form of traumatic (chemical) phlebitis may be deliberately produced by sclerotherapy.
• Thrombophlebitis in a varicose vein
  • Superficial thrombophlebitis frequently occurs in varicose veins. It may extend up and down the saphenous vein or may remain confined to a cluster of tributary varicosities away from the main saphenous vein.
  • Superficial thrombophlebitis along the course of the greater saphenous vein is observed more often to progress to the deep system. Although it may follow trauma to a varix, it often appears to occur without antecedent cause.
  • Thrombophlebitis develops as a tender hard knot in a previously noted varicose vein and is frequently surrounded by erythema. At times, bleeding may occur as the reaction extends through the vein wall. It frequently is observed in varicose veins surrounding venous stasis ulcers.
• Thrombophlebitis as the result of an infection
  • In 1932, DeTakats suggested that dormant infection in varicose veins was a factor in the development of thrombophlebitis occurring at operation or after injection treatments, trauma, or exposure to radiation therapy.³
  • Altemeier and colleagues suggested that the presence of L-forms and other atypical bacterial forms in the blood may play an important etiologic role in the disease and recommended administration of tetracycline.⁴
  • Septic phlebitis usually occurs in association with the long-term use of an intravenous cannula inserted for the administration of fluid or medications.
  • Suppurative thrombophlebitis is a more serious, even lethal, complication of intravenous cannulation and therapy and is characterized by purulence within the vein. It frequently is associated with septicemia.
  • Aerobic and anaerobic as well as mixed infections have been related to superficial venous thrombosis. Aerobic organisms include Staphylococcus aureus, Pseudomonas, and Klebsiella; anaerobic bacteria include Peptostreptococcus, Propionibacterium, Bacteroides fragilis, and more recently, fungi.
• Thrombosis of a hemorrhoid
  • This is another example of superficial venous thrombosis. Evacuation of the thrombus, although very painful, usually provides rapid relief.
  • Magnesium sulfate compresses may also be used to alleviate swelling and pain.
  • Sometimes, surgery is necessary to remove the clot from the hemorrhoid.
• Migratory thrombophlebitis
  • Jadioux first described migratory thrombophlebitis in 1845 as an entity characterized by repeated thromboses developing in superficial veins at varying sites but most commonly in the lower extremity. Although numerous etiologic factors have been proposed, none has been confirmed.
  • The association of carcinoma was first reported by Trousseau in 1856. Sproul noted migratory thrombophlebitis to be especially prevalent with carcinoma of the tail of the pancreas.⁵
  • Phlebitis occurs in diseases associated with vasculitis, such as polyarteritis nodosa (periarteritis nodosa) and Buerger disease. Buerger noted phlebitis in 8 of 19 patients, and Shionoya reported it in 43% of the 255 patients he followed.^6,7
• Thrombophlebitis of the superficial veins of the breast and the anterior chest wall (Mondor disease)
  • Mondor disease is a rare condition. The thrombophlebitis is usually located in the anterolateral aspect of the upper portion of the breast or in the region extending from the lower portion of the breast across the submammary fold toward the costal margin and the epigastrium.
  • A characteristic finding is a tender cordlike structure that may be demonstrated best by tensing the skin by elevating the arm.
  • The cause is unknown, but a search for malignancy is indicated. Mondor disease occurs after breast surgery, with the use of oral contraceptives, and with a protein C deficiency.
  • Thrombophlebitis of the dorsal vein of the penis, generally caused by trauma or repetitive injury, is also referred to as Mondor disease.

Physical

• In each type of superficial thrombophlebitis, the condition presents as redness and tenderness along the course of the vein, usually accompanied by swelling.
• Bleeding also can occur at the site of a varicose vein.
• Superficial thrombophlebitis spontaneously develops in superficial veins, especially in the lower extremities in the greater saphenous vein; this is common in patients with varicose veins.
• Although unusual, it may occur in the lesser saphenous vein, which empties into the popliteal vein.
• Superficial thrombophlebitis of the upper extremities usually occurs at infusion sites or sites of trauma.
• Superficial thrombophlebitis can occur in the external jugular vein if it has been used for an infusion site.

Causes

• Risk factors
  • Varicose veins
  • Obesity
  • Age older than 60 years (fewer complications in this age group)
  • Cigarette smoking
  • Caustic materials, such as lighter fluid and street drugs, injected intravenously
  • Hypercoagulable states such as factor V Leiden mutation, prothrombin gene mutation, and protein S deficiency

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