Superficial Thrombophlebitis

Superficial thrombophlebitis is thrombosis in a superficial vein with an inflammatory reaction. It is usually a benign self-limiting disease but it can be difficult to treat and slow to resolve.

• It is a very common condition.
• Figures are difficult to find but it seems to be more common in those over 60.
• It has a female preponderance.

Risk factors

The 3 cardinal risk factors (the Virchow triad) are:

• Damage to the blood vessel wall (as a result of trauma, infection, or inflammation)
• Stasis of blood flow
• Hypercoagulability of blood

Other more specific risk factors include:

• Obesity
• Thrombophilia
• Smoking
• Oral contraceptives
• Pregnancy
• Intravenous drug abuse

It tends to occur in the postpartum period and does not imply other risk such as thrombophilic disorders.¹ It may occur where an intravenous infusion has been placed, especially if a caustic substance was infused.

There are various different presentations of superficial thrombophlebitis:

• Superficial thrombophlebitis usually occurs in the lower extremities but occurs also in the penis and the breast (Mondor disease).
• Traumatic thrombophlebitis follows an injury. There is a tender cord along the course of a vein and bruising.
• Thrombophlebitis frequently occurs with an intravenous cannula. Either the cannula or the infusion, including drugs may have caused the inflammation. A small lump may appear days or weeks after the cannula has been removed and it can take months to resolve completely. The common sites coincide with those of common medical interventions (arm or neck with external jugular vein cannulation).
• Iatrogenic chemical phlebitis is deliberately produced by sclerotherapy.
• Thrombophlebitis in a varicose vein develops as a tender hard knot in the vein. There is often erythema and bleeding may occur as the reaction extends through the vein wall. It is common with venous stasis ulcers.
• Septic phlebitis usually occurs with long-term use of an intravenous cannula. It is also common in intravenous drug abusers who use dirty equipment and have poor technique.
• Suppurative thrombophlebitis is a serious complication when there is pus in the vein and septicaemia may develop.
• Thrombosis of a haemorrhoid or perianal haematoma is a superficial thrombophlebitis. Incision and removal of the thrombus relieves the condition.

Signs

• There is redness and tenderness along the vein with swelling.
• Spontaneous thrombophlebitis usually develops in the greater saphenous vein, often with varicose veins.

• Cellulitis
• Deep Vein Thrombosis
• Lymphangitis
• Ruptured medial head of gastrocnemius
• Tendonitis

• Usually no further investigation is indicated.
• Duplex scanning is accurate² and may show greater extension into the deep veins than was originally thought.³ The scan should be repeated after treatment to confirm success.
• Venography is not usually required and should be avoided if possible as the contrast medium may aggravate the condition.
• If a septic cannula is suspected, it should be removed and sent for culture.
• Migratory thrombophlebitis requires investigation for underlying malignancy.

• Recurrent thromboses in superficial veins at various sites is called migratory thrombophlebitis and is a pointer for malignancy, especially carcinoma of the tail of pancreas.
• Phlebitis occurs in diseases associated with vasculitis, such as polyarteritis nodosa and Buerger's disease. Buerger reported this in 1909.

Non-drug

• Elastic support of the limb reduces swelling and eases discomfort.
• Severe thrombophlebitis requires bedrest with elevation of the extremity and the application of large, hot, wet compresses, although the evidence base for their effectiveness is limited. Care must be taken to avoid burning the patient. The immobilisation is probably as beneficial as the moist heat.

Drugs

• NSAIDs are often used to relieve pain and to reduce inflammation.
• The value of NSAIDs in resolving the condition, rather than simply as analgesics, seems limited but low molecular weight heparin offers no additional benefit.⁴
• Anticoagulants are only indicated if there is extension into the deep venous system. However, if the long or short saphenous veins are involved, anticoagulation should be considered as the risk of progression to DVT is high.⁵
• Antibiotics are only required if there is infection.

Surgical

If there is persistence or spread of the thrombophlebitis, the vein should be excised. This is important if disease of the greater saphenous vein extends up towards the femoral vein in the groin.⁶

• Extension into the deep veins.
• Suppurative phlebitis can lead to metastatic abscesses and septicaemia.
• Hyperpigmentation over the vein.
• Persistent firm nodule in subcutaneous tissues at the affected site.

• The prognosis is usually good but the disease process will persist for 3 or 4 weeks or more. If it occurs in association with varicose veins there is a high risk of recurrence unless the vein is excised.
• It rarely leads to pulmonary embolism, although it can occur if the process extends into a deep vein.
• People with superficial venous thrombosis do not seem predisposed to develop deep venous thrombosis but superficial venous thrombosis does frequently occur in association with deep venous thrombosis, especially with stasis ulceration around the ankle.
• Where venous thrombo-embolism precedes thrombophlebitis there is an increased risk of further deep vein thrombosis and possible pulmonary embolism.⁷