eMedicine Specialties > Vascular Surgery > Medical Topics

Superficial Thrombophlebitis

Nelson Menezes, MD, RVT, Chief of Vascular Surgery, Assistant Professor, Department of Surgery, Division of Vascular Surgery, The Brooklyn Hospital Center and Cornell University

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

Differential Diagnoses

Cellulitis
Deep Venous Thrombosis

Other Problems to Be Considered

Lymphangitis
Neuritis
Ruptured medial head of the gastrocnemius
Tendonitis

Workup

Laboratory Studies

• Patients who present with spontaneous thrombophlebitis without a previous indwelling intravenous catheter or other precipitating cause should be considered for evaluation for a hypercoagulable state.
  • Certainly, all patients with a past history of another thromboembolic event should undergo a workup. Evaluation should include tests for factor V Leiden and prothrombin gene mutations, protein C and protein S, antithrombin C, antiphospholipid antibodies, lupus anticoagulant, factor VIII, and homocysteine.
  • Schonauer et al reported a high factor VIII concentration to be an independent risk factor for recurrent superficial thrombosis after another episode of venous thromboembolism.⁸ de Godoy and Braile reported that 5.5% of patients with repetitive superficial thrombophlebitis were positive for protein S deficiency.⁹ Other authors have reported that both factor V Leiden and the prothrombin gene mutation significantly increases the risk of superficial thrombophlebitis.
• Migratory thrombophlebitis, especially without good cause, may be an indication for a more detailed evaluation of the patient in search of a malignant lesion. This also should include selective application of serum carcinoembryonic antigen (CEA), prostate-specific antigen (PSA), colonoscopy, CT scans, and mammography.

Imaging Studies

• Duplex ultrasound evaluation is the diagnostic study of choice to search for venous thrombosis. Thrombosed veins may appear thickened or inflamed on ultrasound, but the most diagnostic finding is a lack of compressibility of the vein using the scan head. An experienced ultrasound technologist should be able to diagnose superficial thrombophlebitis with a high sensitivity and specificity. A key question concerns the location and extent of superficial thrombosis, as well as the proximity to the deep venous system at the saphenofemoral or saphenopopliteal junction. Lutter and associates reported that 12% of 186 patients with superficial thrombophlebitis of the great saphenous vein above the knee had extension into the deep venous system.¹⁰
• Venography is rarely required to diagnose superficial thrombophlebitis. It should generally be avoided because of the potential complications of intravenous contrast administration, which can itself lead to phlebitis. Venography is not necessary to exclude the diagnosis of deep vein thrombosis, which can be excluded with duplex scanning. If information on the pelvic veins or iliac venous outflow tract is required, CT venography is usually preferable, if available.
• After an initial diagnosis of superficial thrombophlebitis, especially in the thigh region, a follow-up duplex ultrasound examination should be performed to look for progression of disease after treatment is initiated. A finding of no clot extension indicates successful therapy; thrombus extension or encroachment toward the deep venous system should prompt more aggressive treatment.

Procedures

• With persistence or spread of the process, the thrombophlebitic vein may be excised. Patients who demonstrate signs and symptoms of septic thrombophlebitis require urgent vein excision to control the septic focus. This is usually performed through a direct incision over the vein, allowing removal of the infected thrombosed segment along with wide debridement of any surrounding infected or necrotic tissue. Cultures are sent to guide antibiotic therapy.
• Surgical treatment may also be considered for patients with saphenous thrombophlebitis. This is most often considered if the process extends upward toward the femoral vein or popliteal vein despite anticoagulation or in a patient with a contraindication to systemic anticoagulation. Whether surgical ligation or anticoagulation is the best initial treatment for saphenous thrombosis without deep venous involvement remains controversial. If saphenous ligation is chosen, high ligation at the saphenofemoral or saphenopopliteal junction is recommended with ligation of any branches near the junction. For saphenopopliteal procedures, ultrasound mapping for guidance is recommended because of the variability in location of the saphenopopliteal anatomy.
• If a vein segment involved with superficial thrombophlebitis is suspected to be a source of bacteremia but does not require excision, it can be aspirated in order to culture the contents of the vein lumen. This may be helpful in immunocompromised patients with phlebothrombosis and positive blood cultures.

Histologic Findings

Histologic findings include inflammatory reaction in the vein wall and thrombus in the lumen of the vein.

Treatment

Medical Care

The treatment of superficial venous thrombosis depends on its etiology, extent, and symptoms. Duplex scanning gives an accurate appraisal of the extent of disease and thus allows determining more rational therapy.

• For the superficial, localized, mildly tender area of thrombophlebitis that occurs in a varicose vein, treatment with mild analgesics, such as aspirin, and the use of some type of elastic support usually are sufficient. Patients are encouraged to continue their usual daily activities. If extensive varicosities are present or if symptoms persist, phlebectomy of the involved segment may be indicated.
• More severe thrombophlebitis, as indicated by the degree of pain and redness and the extent of the abnormality, should be treated by bedrest with elevation of the extremity and the application of massive, hot, wet compresses. The latter measure seems to be more effective when a large, bulky dressing, including a blanket and plastic sheeting followed by hot water bottles, is used, taking care to avoid burning the patient. The immobilization is probably as beneficial as the moist heat. Long-leg heavy-gauge elastic stockings or multiple elastic (Ace) bandages are indicated when the patient becomes ambulatory.
• Patients who present with thrombosis of the long or short saphenous veins should be considered for anticoagulation or ligation of the saphenous vein. A high incidence (6-44%) of concurrence or progression to deep venous thrombosis has been reported. Ascher et al reported that 65.6% of patients who present with long saphenous vein thrombosis were found to have associated deep vein thrombosis.¹¹ Optimal treatment of saphenous thrombosis remains controversial. As noted by Wichers et al in a recent systematic review, a lack of randomized trials prevents evidence-based recommendations in this area.¹²
  • In a small randomized trial of 60 patients with long saphenous thrombosis, Lozano et al compared treatment using low molecular weight heparin (LMWH) with surgical saphenous ligation.¹³ Patients in the LMWH group experienced no episodes of deep vein thrombosis or pulmonary embolism but had a 10% incidence of recurrent superficial vein thrombosis. Patients treated surgically were found to have 2 pulmonary emboli (6.7%) and 1 episode of recurrent superficial vein thrombosis (3.3%).
  • In a larger randomized trial (Stenox study), 436 patients with superficial vein thrombosis were randomized to placebo treatment compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or 2 doses of LMWH. All patients wore compression stockings. No statistical difference in the incidence of deep vein thrombosis or pulmonary embolism between the groups was found. The placebo group had a higher incidence of recurrent superficial vein thrombosis than the other 3 groups. Interestingly, the group treated with NSAIDs was no different than those treated with LMWH.
  • Wichers et al conclude, after systematic review of the literature, that LMWH or NSAID therapy appears to reduce the incidence of superficial vein thrombosis extension or recurrence.¹² Larger trials are likely required to demonstrate differences in the incidence of deep vein thrombosis. Treating patients with some form of low- or intermediate-dose anticoagulation appears reasonable at this time, followed by repeat duplex ultrasound to look for progression at intervals for a few weeks to a month. In patients with stable nonprogressing thrombus, anticoagulation therapy can probably be discontinued in the absence of other risk factors.
  • Patients with contraindications to anticoagulation or those receiving adequate anticoagulation treatment who have progression of thrombosis should be considered for saphenous ligation at the junction with the deep venous system.
• If the thrombophlebitis is associated with a cannula or a catheter, the device should be immediately removed and cultured. If the patient is septic, appropriate antibiotics should be given. If suppurative thrombophlebitis is suspected, immediate and complete excision of all of the involved veins is indicated. The wound may be left packed open for secondary closure or skin grafting at a later date. The use of appropriate systemic antibiotics is always indicated.
• If the suppurative process involves one of the deep veins, aggressive antimicrobial and anticoagulant therapy are necessary.

Activity

In the early phases of superficial thrombophlebitis in the leg, dangling the extremity without external support from stockings or elastic bandages leads to leg swelling and increased pain.

Medication

Some anti-inflammatory drugs may be of benefit. Salicylates, indomethacin, and ibuprofen have been reported to be effective. Salicylates, ibuprofen, and dipyridamole have been used as antithrombotic agents, but their effectiveness has not been documented in this setting. Because thrombophlebitis is primarily due to inflammation and fibrin clot, antithrombotic or antiplatelet-aggregating agents would seem to have little value. Anticoagulants are usually not indicated unless the process extends into the deep venous system. In rare cases when persistent inflammation is present in an area of superficial thrombophlebitis, a brief course of LMWH can be used as an alternative to excision of the vein in order to bring the inflammation under control. This treatment alternative may be necessary for management of superficial thrombophlebitis associated with pregnancy.

Antibiotics are usually not necessary unless the process is suppurative. In persistent cases or even as early definitive therapy, excision of the inflammatory process is effective. The wounds usually heal well with primary closure; the inflammatory process, except in suppurative phlebitis, is usually nonbacterial and localized and is removed completely.

Nonsteroidal anti-inflammatory drugs

These agents decrease inflammatory responses and systemically interfere with events leading to inflammation.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for patients with mild-to-moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Indomethacin (Indochron E-R, Indocin)

Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Dosing

Adult

25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d

Pediatric

1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; GI bleeding or renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occur)

Follow-up

Further Outpatient Care

Follow up in 2-3 days, either with an office visit or by telephone, to be sure the patient is progressing in a satisfactory manner.

Complications

• Extension into the deep venous system
• Complications of suppurative phlebitis include the following:
  • Metastatic abscess formation
  • Septicemia
• Hyperpigmentation over the affected vein
• Persistent firm nodule in subcutaneous tissues at site of affected vein

Prognosis

• The prognosis is usually good.
• Superficial phlebitis is rarely associated with pulmonary embolism, although it can occur, particularly if the process extends into a deep vein.
  • Individuals with superficial venous thrombosis do not seem to have a great tendency to develop deep venous thrombosis; however, duplex scanning may prove this assumption wrong.
  • Superficial venous thrombosis, on the other hand, does occur frequently in association with deep venous thrombosis, especially in patients with ulceration around the ankle.
• The patient should be told to expect the disease process to persist for 3-4 weeks or longer. If it occurs in the lower extremity in association with varicose veins, it has a high likelihood of recurrence unless excision is performed.

Patient Education

• Because thrombophlebitis tends to recur if the vein has not been excised, instructing the patient in ways to prevent stasis in the vein is usually advisable.
  • The use of elastic stockings may be indicated, especially if the patient plans to stand in an upright position for long periods.
  • Slight elevation of the foot of the bed, avoidance of long periods of standing in an upright position, or inactivity is recommended.
• 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

Medicolegal Pitfalls

Failure to perform duplex scanning in the presence of superficial thrombophlebitis to exclude deep vein thrombophlebitis is one medicolegal pitfall.

References

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Keywords

superficial thrombophlebitis, venous clot, venous swelling, vein clot, vein swelling, thrombophlebitis, thrombosis, venous thrombosis, vein thrombosis, vein thrombus, deep vein thrombosis, deep venous thrombosis, pulmonary embolism, superficial venous thrombosis, traumatic thrombophlebitis, Mondor disease

Contributor Information and Disclosures

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
Nelson Menezes, MD, RVT is a member of the following medical societies: American College of Surgeons, International Society of Endovascular Specialists, Medical Society of the State of New York, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Lawrence Kaufman, MD, Associate Professor, Department of Surgery, Division of Vascular Surgery, Tufts University School of Medicine
Jeffrey Lawrence Kaufman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society for Artificial Internal Organs, Association for Academic Surgery, Association for Surgical Education, Massachusetts Medical Society, Phi Beta Kappa, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William A. Marston, MD, to the development and writing of this article.

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