Guidelines

Acta chir belg, 2005, 105, 145-147

Superficial Thrombophlebitis of the Lower Limb : Practical Recommendations for Diagnosis and Treatment
M. G. R. De Maeseneer* Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Belgium. (*) On behalf of the Thrombosis Guidelines Group of the Belgian Society on Thrombosis and Haemostasis and the Belgian Working Group on Angiology : S. Motte ULB Erasme Anderlecht, G. Baele UZ Gent, P. Cauchie CHU Charleroi, JL. David CHU Sart-Tilman Lige, K. De Boeck AZ Middelheim Antwerpen, V. Deneys UCL St Luc Bruxelles, M. Dicato CH Luxembourg, L. Gilis St-Nikolaus Eupen, P. Hainaut UCL St Luc Bruxelles, C. Hermans UCL St Luc Bruxelles, K. Jochmans AZ-VUB Jette, K. Peerlinck KUL UZ Gasthuisberg Leuven, M. Vanderplancken UZA Antwerpen, R. Verhaeghe KUL UZ Gasthuisberg Leuven, K Von Kemp AZ-VUB Jette, J Wautrecht ULB Erasme Anderlecht, M. Zicot CHR Citadelle Lige.

Key words. Great saphenous vein ; small saphenous vein ; superficial thrombophlebitis ; duplex ultrasonography ; anticoagulant treatment ; surgical treatment.

Superficial thrombophlebitis (ST) of the lower limb has long been considered as a benign disease, with an easy clinical diagnosis and requiring only a simple conservative management. However recent investigations suggest that the course of this disease is not always as benign and self-limiting as described. Therefore, to optimise the diagnosis and treatment of ST, some important issues have to be addressed. Diagnosis of superficial thrombophlebitis : the role of duplex scan The clinical presentation of ST is usually quite clear-cut, especially in a patient with pre-existing varicose veins. There is often a history of local trauma. Clinical examination reveals the presence of a tender wormlike mass deep to the skin. The overlying skin is warm and red. Often there is some oedema of the surrounding tissue, without generalized oedema of the limb. In a patient without history of varicose veins, ST presents as a red, hot, painful cord along the course of a non-varicose vein. The clinical signs of thrombophlebitis may change from one localization to the other and appear as thrombophlebitis migrans. The real extent of the ST will often be underestimated if the diagnosis is based solely on clinical examination. Duplex scan appears to be very useful to illustrate up to which level the thrombus is ascending. Moreover duplex ultrasound may reveal the presence of an associated deep vein thrombosis (DVT), which is often asymptomatic and therefore not detected at clinical examina-

tion alone. Such occult DVT (thrombose muette) may be caused by two possible mechanisms. Direct extension of the thrombus from the superficial into the deep vein at the level of the sapheno-femoral junction, the sapheno-popliteal junction or perforating veins (per continuitatem or ascending) is the most obvious mechanism. However DVT can also occur as a non-contiguous thrombosis, in the ipsi- or contralateral leg. The incidence of associated DVT has been described to be 515% (1-4). BOUNAMEAUX (5) reported an incidence of associated DVT of 5.6% in a large retrospective study of 551 cases of ST. He suggested that systematic screening for DVT might not be warranted in patients with ST unless additional risk factors were present (such as previous immobilization). In a recent study of DECOUSUS (6) associated DVT or pulmonary embolism was found in 120 (13.8%) of the 867 patients with ST screened before enrolment, and further developed in 4.5% of the placebo treated group during an observation period of 3 months. Symptomatic pulmonary embolism (PE) was seen in 1% of 232 patients with ST diagnosed on duplex ultrasound (7). In a small patient group with ST of the great saphenous vein (GSV) in the above-knee segment an unexpectedly high incidence of asymptomatic PE was reported (8). However up to now there are no large studies confirming these findings and therefore systematic lung scan is not warranted. Recently, factors predictive of venous thrombotic complications were studied in patients with isolated symptomatic superficial vein thrombosis (9). Venous thrombotic complications were defined as DVT or PE,

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or recurrence or proximal extension of ST. They were more likely to occur in men, in patients with a history of venous thromboembolism or with severe chronic venous insufficiency, or in whom the ST was recent. Recommendation : To assess the real extent of the ST and to detect a possible associated DVT, (bilateral) duplex examination is recommended in all cases of ST of the main trunk of the great saphenous vein (GSV) or of the main trunk of the small saphenous vein ( SSV). Underlying etiologic conditions in patients with superficial thrombophlebitis The majority of patients with ST have pre-existing varicose veins. In a prospective study of 100 patients with ST, Gillet (3) found 88% of patients with varicose veins (VV) and only 12% with non-varicose veins (NVV). In the NVV patients various underlying conditions may be recognised such as thrombophilia (factor V Leiden mutation, antithrombine deficiency, protein C or S deficiency...), systemic disorders (Brger disease, Behets syndrome, antiphospholipid syndrome,...) and malignant disease. In some rare instances of so-called idiopathic ST no underlying etiology can be found. In patients with VV, ST limited to a varicose tributary may be exclusively due to underlying venous stasis. In such cases the ST is often induced by a banal trauma of a varicose vein and may be considered a self-limiting condition. However, when a more extensive ST is situated in the main saphenous trunk, venous stasis is often not the only etiologic factor contributing to ST. Associated thrombophilia can also be found in this particular patient group in 15% of cases (3). In an earlier study Becker stated that underlying carcinoma was present in 5-20% of cases of GSV thrombophlebitis (10). Recommendation : We suggest to look carefully for underlying predisposing factors in patients with ST in non-varicose veins. Treatment of superficial thrombophlebitis Various therapeutic measures are at disposition and will be applied depending on the severity of the ST : local anti-inflammatory applications (gel, cream, spray) local incision with expression of clots compression (bandages, stockings) immediate mobilisation (walking exercises) analgesics or anti-inflammatory drugs surgery : high ligation / complete varicose vein surgery anticoagulation : unfractionated heparin (UFH), low molecular weight heparin (LMWH) in prophylactic or therapeutic dose, oral anticoagulants

M. G. R. De Maeseneer
In some cases of ST, the therapeutic strategy will be obvious. In patients with a limited ST in a varicose collateral vein local treatment and mobilisation with elastic compression will be sufficient (11). The role of the use of short-term prophylactic low molecular weight heparin (LMWH) in these cases has not been established. In a second stage surgical correction of the underlying varicose veins can be planned. In patients with a ST with an associated DVT, the treatment will of course correspond to the usual DVT treatment (LMWH, oral anticoagulants, elastic compression, immediate mobilisation). However, in cases of extensive ST involving the main trunk of the GSV or SSV, and sometimes ascending up to the junction with the deep vein, there is less evidence about the optimal treatment strategy. In patients with previous varicose veins, surgery including high ligation, stripping and excision of varicose veins seems to be a good option for extensive ST of the above-knee GSV and for ST of the SSV with extension nearby the sapheno-popliteal junction (1, 12, 13). In Belcaros comparative study in patients, who were treated with simple flush ligation, more thrombus extension was observed after 3 and 6 months than in patients who had undergone complete varicose vein surgery (12). Therefore, in case of immediate surgical treatment of the ST, a complete procedure should be performed. However caution is warranted during surgical intervention, especially in cases with severe inflammatory reaction around the vein, which will result in higher postoperative morbidity than elective procedures (13). Postoperative prophylactic LMWH should be continued in all operated cases of ST during 7-10 days after surgery. In patients with ST in a previously healthy vein, surgery is not indicated. If possible, in these patients the underlying disease should be treated. A good alternative treatment for patients with extensive ST without deep vein involvement consists in anticoagulant therapy with LMWH and/or oral anticoagulants. In an older study LMWH during 6 days already seemed to be superior to non-steroidal anti-inflammatory drugs in reducing symptoms and signs (14). Recent data from a randomised controlled trial demonstrated the efficacy of unfractionated heparin (UFH) in an unmonitored high dose (12.500 IU twice a day) during 4 weeks (15). In their discussion the authors suggested that UFH could be conveniently replaced by LMWH in therapeutic doses. In another randomised controlled trial Decousus reported that LMWH during 10 days initially reduced the development of thrombo-embolic complications, but after three months this beneficial effect was less clear (6). Prophylactic doses seemed to be as effective as therapeutic doses, but a total duration of only 10 days of LMWH treatment might have been too short to obtain satisfying long term results. Good results have been obtained with an extended therapeutic scheme

Superficial Thrombophlebitis
(30 days) : 10 days of LMWH in full therapeutic dose followed by 20 days of LMWH in half-therapeutic dose together with immediate mobilisation and elastic compression (unpublished data). The experts of the seventh American College of Chest Physicians (ACCP) conference on antithrombotic therapy recently suggested intermediate dosages of UFH or LMWH for at least 4 weeks (16). Further studies are needed to establish the value of treatment of extensive ST with LMWH in reducing thrombo-embolic complications and in preventing extension of thrombus in the superficial veins (17). Different dosage schemes and duration of treatment should be compared. The economic aspects (cost/benefit) of different therapeutic regimens should also be taken into account, as LMWHs are expensive (12). An alternative could consist in the use of oral anticoagulants during 3 months after a short initial LMWH treatment (18). Recommendations : In all cases of ST immediate mobilisation with elastic compression is mandatory. Most patients with limited ST do not need anticoagulation but only need local treatment. Extensive ST involving the main trunk of the GSV or SSV may be treated with immediate surgery or anticoagulant therapy, consisting in LMWH or oral anticoagulants. LMWH may offer an attractive alternative to oral anticoagulation. As yet no clear recommendations can be made concerning the dosage and duration of anticoagulation. However it appears useful to treat patients with extensive ST during more than 10 days. For a treatment up to four weeks LMWH is the first option, while oral anticoagulation is preferred for prolonged treatment. References
1. KALODIKI E., NICOLAIDES A. N. Superficial thrombophlebitis and low-molecular-weight heparins. Angiology, 2002, 53 : 659-63. 2. GUEX J. J. Thrombotic complications of varicose veins. Dermatol Surg, 1996, 22 : 378-82. 3. GILLET J. L., PERRIN M., CAYMAN R. Thromboses veineuses superficielles des membres infrieurs. Journal des Maladies Vasculaires, 2001, 26 : 16-22. 4. SKILLMAN J. J., KENT K. G., PORTER D. H., KIM D. Simultaneous occurrence of superficial and deep thrombophlebitis in the lower extremity. J Vasc Surg, 1990, 11 : 818-24.

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5. BOUNAMEAUX H., REBER-WASEM M. Superficial thrombophlebitis and deep vein thrombosis. Arch Inernt Med, 1997, 157 : 1822-24. 6. DECOUSUS H. (The superficial thrombophlebitis treated by enoxaparin study group). A pilot randomised double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis. Arch Intern Med, 2003, 163 : 1657-63. 7. BLUMENBERG R. M., BARTON E., GELFAND M. L., SKUDDER P., BRENNAN J. Occult deep venous thrombosis complicating superficial thrombophlebitis. J Vasc Surg, 1998, 27 : 338-43. 8. VERLATO F., ZUCCHETTA P., PRANDONI P., CAMPORESE G., MARZOLA M. C., SAMISTRARO G., BUI F., MARTINI R., ROSSO F., ANDREOZZI G. M. An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh. J Vasc Surg, 1999, 30 : 1113-5. 9. QUENET S., LAPORTE S., DECOUSUS H., LEIZOROVICZ A., EPINAT M., MISMETTI P. Factors predictive of venous thrombotic complications in patients with isolated superficial vein thrombosis. J Vasc Surg, 2003, 38 : 944-9. 10. BECKER F. Thromboses veineuses superficielles des membres infrieus. La revue du practicien, 1996, 46 : 1225-8. 11. RAAKE W., BINDER M. Behandlung der oberflchlichen Thrombophlebitis. Hmostaseologie, 2002, 22 : 149-53. 12. BELCARO G., NICOLAIDES A. N., ERRICHI B. M., CESARONE M. R., DE SANCTIS M. T., INCANDELA L., VENNIKER R. Superficial thrombophlebitis of the legs : A randomized, controlled, follow-up study. Angiology, 1999, 50 : 523-29. 13. SULLIVAN V., DENK P. M., SONNAD S. S., EAGLETON M. J., WAKEFIELD T. W. Ligation versus anticoagulation : treatment of above-knee superficial thrombophlebitis not involving the deep venous system. J Am Coll Surgl, 2001, 193 : 556-62. 14. TITON J. P., AUGER D., GRANGE P., HECQUET J. P., REMOND A., ULLIAC P., VAISSI J. J. Traitement curatif des thromboses veineuses superficielles par nadroparine calcique. Ann Cardiol Angiol, 1994 , 43 : 160-66. 15. MARCHIORI A., VERLATO F., SABBION P., CAMPORESE G., ROSSO F., MOSENA L., ANDREOZZI G. M., PRANDONI P. High versus low doses of unfractionated heparin for the treatment of superficial thrombophlebitis of the leg. A prospective, controlled, randomized study. Haematologica, 2002, 87 : 523-27. 16. BLLER H. R., AGNELLI G., HULL R. D., HYERS T. M., PRINS M. H., RASKOB G. E. Antithrombotic therapy for venous thromboembolic disease. The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest, 2004, 126 suppl 401S-428S. 17. PARTSCH H. Diagnostik und Therapie der Thrombophlebitis unter besonderer bercksichtigung niedermolekularer Heparine. Hmostasealogie, 2002, 22 : 154-60. 18. BATES S. M., HIRSCH J. Treatment of venous thromboembolism. Thromb Haemost, 1999, 82 : 870-77. M. De Maeseneer Department of Thoracic and Vascular Surgery University Hospital Antwerp Wilrijkstraat 10 B-2650 Edegem, Belgium Tel. : (32) 3 821 43 48 Fax : (32) 3 821 43 96 E-mail : marianne.de.maeseneer@uza.be