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WDIDN: Superficial Thrombophlebitis - Etiology and Management

Andy Little, DO, Mike Weinstock, MD, and Matthew DeLaney, MD
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The prevalence of venous thrombus of the upper and lower extremity are a common etiology patients are evaluated for by clinicians in the urgent and emergency department setting. Although Deep Venous Thrombosis (DVT) is a considerably more worrisome diagnosis, it is important to understand the presentation, physical exam and the management of superficial thrombophlebitis.

 

Pearls:

  • Superficial thrombophlebitis most commonly occurs after trauma to a vessel.

  • ¼ patients with superficial thrombophlebitis have a concomitant DVT. 

  • Distal thrombophlebitis has a low association with DVT.

  • Use of Wells Criteria is helpful for determining the probability of DVT in patients with superficial thrombophlebitis. 

  • Mild (<5cm) superficial thrombophlebitis is treated with NSAIDs and warm compresses.

  • Anticoagulation is recommended for thrombophlebitis >5cm. 

 

Definition

  • The presence of a blood clot in a superficial vein.

  • Most commonly superficial thrombophlebitis is provoked by trauma to the vessel by IV catheters, PICC lines, IV drug use, or blunt trauma to the extremity.  

  • Superficial thrombophlebitis alone is not felt to predispose to pulmonary embolism.

    • It is important to consider the possibility of concomitant DVT when evaluating patients with superficial thrombophlebitis. 

    • ¼ patients with thrombophlebitis have a co-existent DVT.

Physical Exam

  • Tenderness

  • Palpable lump or “cord” 

  • Limb swelling distal to the site of the clot

 

  • It is prudent to get a venous duplex ultrasound on patients with suspected large and/or proximal thrombophlebitis given high risk of associated DVT (~25%).

    • Distal thrombophlebitis (ie: below the knee or elbow) has a low risk for DVT and generally can forego venous duplex US unless other concerns for DVT exist (e.g. h/o DVT, metastatic cancer, pregnancy, high Wells score). 

  • Mild (<5 cm clot) superficial thrombophlebitis can be treated conservatively with NSAIDs and warm compresses. 

  • Severe (>5 cm clot)/proximal thrombophlebitis should be treated with anticoagulation.

    • Clot within 3 cm of the sapheno-femoral junction should also be treated as DVTs. 

  • Venous duplex does not need to be performed stat and ED referral is rarely necessary; it is generally reasonable to arrange for outpatient US within several days.

    • It is prudent to start anticoagulation for patients at high risk of DVT by Wells Criteria (or similar clinical decision rule) until venous duplex US is performed. 

    • Choice of anticoagulation can be low molecular weight heparin subQ or with direct oral anticoagulants (DOACs), such as rivaroxaban or apixaban.

  • Studies evaluating aspirin and other NSAIDs for superficial thrombophlebitis have all shown similar benefits, so any NSAID is reasonable.

    • It is unclear if the antiplatelet effect of aspirin affects recovery.  

 

References 

  1. Frappe P, et al the STEPH Study Group. Annual diagnosis rate of superficial-vein thrombosis of the lower limbs: the STEPH community-based study. J Thromb Haemost 2014; 12: 831–8. PMID: 24679145

  2. White R. The epidemiology of venous thromboembolism. Circulation 2003; 107: I4–8. PMID: 12814979

  3. Blumenberg R, et al.: Occult deep venous thrombosis complicating superficial thrombophlebitis. J Vasc Surg 1998, 27:338– 343. PMID: 9510288

  4. Coon W, et al. Venous thromboembolism and other venous disease in the Tecumseh Community Health Study. Circulation 1973;48:839–846. PMID: 4744789

  5. Cosmi B. Management of superficial vein thrombosis. Journal of thrombosis and haemostasis : JTH. 13(7):1175-83. 2015. PMID: 25903684

  6. Guyatt G, et al. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):7S-47S. 2012. PMID: 22315257

  7. Decousus H, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. The New England journal of medicine. 363(13):1222-32. 2010. PMID: 20860504

  8. Bauersachs R. Diagnosis and treatment of superficial vein thrombosis. Hämostaseologie. 33(3):232-40. 2013. PMID: 23757000

  9. Kearon C, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e419S-94S. 2012. PMID: 22315268

  10. Grigorian A, et al. Upper Extremity Deep Venous Thrombosis. [Updated 2020 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482420/

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