Superficial Thrombophlebitis Treatment & Management

  • Author: Nelson S Menezes, MD, FRCS(Edin), FACS; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Feb 27, 2009
 

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.
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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.

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Contributor Information and Disclosures
Author

Nelson S Menezes, MD, FRCS(Edin), FACS  Assistant Professor of Surgery, Weill Cornell Medical College; Chief of Vascular Surgery, Department of Surgery, Brooklyn Hospital Center

Nelson S Menezes, MD, FRCS(Edin), FACS 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Acknowledgments

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.

References

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