Superficial Thrombophlebitis Workup

  • Author: Nelson S Menezes, MD, FRCS(Edin), FACS; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Mar 5, 2012
 

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.[9] de Godoy and Braile reported that 5.5% of patients with repetitive superficial thrombophlebitis were positive for protein S deficiency.[10] 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.
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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.[11]
  • 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.
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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.
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Histologic Findings

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

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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 Program Director, Vascular Surgery Residency

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.

Additional Contributors

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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