Superficial thrombophlebitis occurs when a superficial vein (usually the long saphenous vein of the leg or its tributaries), becomes inflamed and the blood within it clots. It may be spontaneous, or associated with one or more risk factors, e.g. varicose veins.

It is usually a benign self-limiting disease but it can be difficult to treat and slow to resolve.

Epidemiology

This is a very common condition and, although figures are difficult to find, it seems to be more common in those aged over 60. It has a female preponderance and seasonal variation (more common in warmer months) has also been reported.¹

Risk factors

The three cardinal risk factors (Virchow's triad) are:

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

Other specific risk factors include:

• Obesity.
• Thrombophilia.
• Smoking.
• Oral contraceptives.
• Pregnancy.²
• Intravenous drug abuse.
• Intravenous infusion (especially if an irritant substance was infused).³

Presentation

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's 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.

Differential diagnosis

• Cellulitis.
• Deep vein thrombosis (DVT).
• Lymphangitis.
• Ruptured medial head of gastrocnemius.
• Tendonitis.

Investigations

• Usually no further investigation is indicated.
• 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.

Associated diseases

• 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.^4,5
• Phlebitis occurs in diseases associated with vasculitis, such as polyarteritis nodosa and Buerger's disease. Buerger reported this in 1909.

Management

General measures

• Elastic support of the limb reduces swelling and eases discomfort.
• Severe thrombophlebitis requires bed rest 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.
• Exercise reduces pain and the possibility of deep vein thrombosis (DVT). Only in cases in which pain is very severe is bed rest necessary. DVT prophylaxis should be established in patients with reduced mobility.⁶

Pharmacological

• Topical analgesia with nonsteroidal, anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms.
• Hirudoid® cream (heparinoid) shortens the duration of signs/symptoms, although there is some evidence to suggest that heparin gel 1,000 IU/g may be more effective.^6,7
• An intermediate dose of low molecular weight heparin for at least a month might be advisable, although data currently available are too limited to make clear recommendations.⁸ Further research is needed to assess optimal doses and duration of treatment and whether a combination therapy may be more effective than a single treatment.
• Fondaparinux® at a dose of 2.5 mg once a day for 45 days has been reported to lower the risk of pulmonary embolism (PE) or DVT by 85%.⁹ There were few adverse events and the number needed to treat was 88 (to prevent 1 PE or DVT).

Antibiotics are only required if there is evidence of infection.

Surgical

If there are recurrences of the thrombophlebitis associated with extensive varicose veins, they should be excised.

Complications

• Extension into the deep veins.^10,11
• Suppurative phlebitis can lead to metastatic abscesses and septicaemia.
• Hyperpigmentation over the vein.
• Persistent firm nodule in subcutaneous tissues at the affected site.

Prognosis

• 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 (PE), 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 thromboembolism precedes thrombophlebitis, there is an increased risk of further deep vein thrombosis (DVT) and possible pulmonary embolism (PE).¹²

Document references

1. Kakkos SK, Lampropoulos G, Papadoulas S, et al; Seasonal variation in the incidence of superficial venous thrombophlebitis. Thromb Res. 2010 Aug;126(2):98-102. [abstract]
2. Kupelian AS, Huda MS; Pregnancy, thrombophlebitis and thromboembolism: what every obstetrician should Arch Gynecol Obstet. 2007 Mar;275(3):215-7. Epub 2006 Aug 10. [abstract]
3. Eyigor C, Ceylan A, Demir F, et al; Superficial venous thrombophlebitis caused by rocuronium. J Anesth. 2010 Aug;24(4):646-8. Epub 2010 Apr 22. [abstract]
4. Diaconu C, Mateescu D, Balaceanu A, et al; Pancreatic cancer presenting with paraneoplastic thrombophlebitis--case report. J Med Life. 2010 Jan-Mar;3(1):96-9. [abstract]
5. van Weert HC, Pingen F; Recurrent thromboflebitis as a warning sign for cancer: a case report. Cases J. 2009 Oct 13;2:153. [abstract]
6. Cesarone MR, Belcaro G, Agus G, et al; Management of superficial vein thrombosis and thrombophlebitis: status and expert opinion document. Angiology. 2007 Apr-May;58 Suppl 1:7S-14S; discussion 14S-15S. [abstract]
7. Vecchio C, Frisinghelli A; Topically applied heparins for the treatment of vascular disorders : a Clin Drug Investig. 2008;28(10):603-14. [abstract]
8. Di Nisio M, Wichers IM, Middeldorp S; Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004982. [abstract]
9. Decousus H, Prandoni P, Mismetti P, et al; Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010 Sep 23;363(13):1222-32. [abstract]
10. Dewar C, Panpher S; Incidence of deep vein thrombosis in patients diagnosed with superficial Emerg Med J. 2010 Oct;27(10):758-61. Epub 2010 Jun 17. [abstract]
11. Decousus H, Quere I, Presles E, et al; Superficial venous thrombosis and venous thromboembolism: a large, prospective Ann Intern Med. 2010 Feb 16;152(4):218-24. [abstract]
12. Schonauer V, Kyrle PA, Weltermann A, et al; Superficial thrombophlebitis and risk for recurrent venous thromboembolism. J Vasc Surg. 2003 Apr;37(4):834-8. [abstract]

Internet and further reading

• Thrombophlebitis, Clinical Knowledge Summaries (April 2009)
• Menezes N; Superficial Thrombophlebitis, Medscape, Feb 2009

Acknowledgements