Thrombophlebitis Treatment & Management

Updated: Aug 31, 2020
  • Author: Padma Chitnavis, MD; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Medical Care

The location of the thrombosis directs the treatment.

If progression to DVT is suspected or proven, adequate anticoagulation is imperative to prevent PE and other possible long-term complications of DVT.

Low molecular weight heparin (LMWH) or fondaparinux is considered the treatment of choice for SVT, although the appropriate length of treatment is unclear. Forty-five days of treatment is recommended by the American College of Chest Physicians. [118] Topical treatment alone is not adequate. [119] The use of LMWH in patients with SVT may decrease perivascular inflammation. LMWH limits neutrophil extravasation. [120] Thus, LMWH has anti-inflammatory properties in addition to anticoagulant properties. High doses of unfractionated heparin are shown to be more effective in preventing thromboembolic combinations than prophylactic doses. [121]

LMWH and nonsteroidal anti-inflammatory drugs (NSAIDs) both were shown to decrease the incidence of thrombophlebitis spread by approximately 70% in a meta-analysis of 24 studies and nearly 2500 patients. [119] In a small study of 72 patients, LMWH (dalteparin) was found to be superior to NSAIDs (ibuprofen) in preventing extension of DVT. [122]

Alternatively, superficial relapsing superficial venous thrombophlebitis may be treated with subcutaneously placed fondaparinux or oral rivaroxaban. [123] A large review of 30 studies involving 6507 participants with SVT of the legs found a 6-week course of fondaparinux to be a valid therapeutic option. [124]

Patients with extensive involvement of leg varices should receive anticoagulants. This treatment is particularly important if the proximal part of the SFJ is involved. In addition to propagation of the thrombus through the SFJ, 11-40% of patients with SVT at the SFJ have evidence of concurrent DVT. [110, 111, 125, 126] In these patients, anticoagulation for 6 months resolved the DVT or SVT and prevented PE. This success occurred despite duplex ultrasonographic evidence of SVT progression to DVT in 2 of 20 patients. [125]

The role of oral or topical NSAIDs and compression therapy is unclear, as data are insufficient to draw meaningful conclusions. [106] Aspirin or other NSAIDs may be helpful in limiting both inflammation and pain. NSAIDs are associated with lower rates of SVT progression compared with placebo. [106] Adequate graduated compression should be maintained, and the patient should ambulate frequently until the pain and inflammation resolve. In addition to adequate graduated compression, drainage of the thrombi after their liquefaction (approximately 2 wk after onset of the lesion) hastens the otherwise slow, painful resorption process. [127]

Other treatment modalities have been tried but lack conclusive results from large clinical trials. Pycnogenol (an oral antithrombotic agent) has been found to decrease the number of thrombotic events during long-haul flights. [128] Essaven gel improved the signs and symptoms of SVT of the arms. [129] Diclofenac gel and Exhirud ointment are no longer used or are used very infrequently as topical treatments. [119]

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Surgical Care

Emergency surgical interventions may be effective in preventing complications of SVT. [130] Surgical interventions are associated with the lowest incidence of extension of the thrombus and allow the patient to return to work faster than nonsurgical modalities. [128]

Under the appropriate circumstances, incision and drainage of the clot should be attempted to alleviate pain.

If the thrombosis extends into the deep venous system, ligation and stripping of the affected vein should be considered.

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Consultations

SVT can usually be treated conservatively, as described above, unless extension into the deep venous system is imminent.

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Activity

Patients should be encouraged to be ambulatory.

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Prevention

The routine use of graduated support stockings (class I or II), especially when the patient is confined on an airplane or otherwise, is extremely important.

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Long-Term Monitoring

Follow up patients with SVT at weekly intervals until complete resolution occurs to ensure against its progression to DVT.

Routinely monitor patients with DVT, especially while they are receiving anticoagulant therapy.

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