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Superficial Thrombophlebitis

BASICS

  • Definition: Thrombosis-related inflammatory process of superficial veins, most common in lower extremities (esp. greater saphenous vein, 60–80%).
  • Types:
  • Traumatic: Injury, IV catheter, iatrogenic
  • Aseptic: Primary (hereditary), Secondary (stasis, pregnancy, malignancy)
  • Septic (suppurative): Iatrogenic, infectious (IV catheters, syphilis, psittacosis)
  • Mondor disease: Rare, veins of groin, penis, chest, or breast

EPIDEMIOLOGY

  • Mean age: 60 years
  • Sex: 50–70% female; more common with varicose veins
  • Prevalence: 3–11% general population
  • ICU: 1/3 develop thrombophlebitis, often progressing to deep veins
  • Special groups:
  • Septic: extremes of age
  • Mondor: women 21–55 yrs
  • Pregnancy: higher risk, esp. postpartum

ETIOLOGY AND PATHOPHYSIOLOGY

  • Mechanisms: Venous stasis, vessel wall injury, microthrombi/platelet aggregation, hypercoagulable states
  • Varicose veins: Major factor in lower extremity cases
  • Hypercoagulability:
  • Primary (hereditary): Antithrombin III, heparin cofactor II deficiency
  • Secondary (acquired): Malignancy (Trousseau syndrome), pregnancy, estrogen OCPs, Buerger/Behçet
  • Septic: Staph aureus, Pseudomonas, Klebsiella, Candida, others
  • Migratory form: May indicate underlying malignancy

RISK FACTORS

  • Varicose veins, immobilization, obesity, age, surgery, pregnancy/postpartum, OCPs, prior thromboembolism, trauma, tobacco use, hypercoagulable state

PREVENTION

  • Avoid unnecessary catheters, especially in lower limbs
  • Aseptic technique for IVs, rotate/replace every 3 days
  • Early mobilization, DVT prophylaxis in high-risk/immobilized patients
  • Minimize risk factors

ASSOCIATED CONDITIONS

  • DVT (6–53% coexistence), VTE (risk 4–6× higher), pulmonary embolism (0–10% concurrent)
  • Up to 3 months after onset, DVT/PE can occur

DIAGNOSIS

HISTORY

  • Firm, warm, painful cord-like area over superficial vein
  • Possible risk factors (see above)

PHYSICAL EXAM

  • Swelling, tenderness, redness along vein
  • Palpable tender cord with erythema
  • Fever/systemic sepsis possible in septic cases

DIFFERENTIAL DIAGNOSIS

  • Cellulitis, DVT, erythema nodosum, lymphangitis, cutaneous polyarteritis nodosa, contact dermatitis, other vasculitides

DIAGNOSTIC TESTS

  • Diagnosis: Clinical + duplex ultrasound to rule out DVT, especially if proximal/thigh involvement or high risk
  • Sepsis: Blood cultures, CBC (leukocytosis), culture IV fluid/tip if catheter-associated
  • Migratory: Screen for malignancy
  • Recurrent/unprovoked: Consider thrombophilia testing

TREATMENT

GENERAL MEASURES

  • Low-risk, mild/aseptic:
  • NSAIDs/ASA, local compression, elevation, mobilize
  • Compression stockings if varicosities
  • High-risk (above knee, age >65, male, prior VTE, cancer, non-varicose veins):
  • Rivaroxaban 10 mg PO daily x 45 days or fondaparinux 2.5 mg SQ daily x 45 days
  • Catheter/trauma-related: Remove IV, culture tip, warm compresses, consider LMWH if slow to resolve
  • Septic/suppurative:
  • Remove source, IV broad-spectrum antibiotics, urgent surgical excision of affected vein if needed
  • Inpatient care, bed rest, elevation, local warm compress, antibiotics, anticoagulation

MEDICATION

  • First Line:
  • NSAIDs/ASA for pain/inflammation
  • Compression stockings
  • High-risk: Rivaroxaban or fondaparinux 45 days (see above)
  • Second Line:
  • LMWH for large/thigh/proximal/near deep vein/long saphenous vein or if extension
  • 45 days fondaparinux reduces DVT/VTE by 85% (CALISTO study)
  • Septic: IV antibiotics + anticoagulation

REFERRAL/CONSULTATION

  • Severe/inflamed/large: Consider venous excision
  • Septic: Urgent surgical referral
  • Contraindication to anticoagulation: Vascular surgery consult

SURGERY/PROCEDURES

  • Septic: Excision, abscess drainage, remove all cannulas, culture
  • Aseptic: Saphenous vein ligation, consider varicosity excision

ADMISSION & NURSING

  • Septic: Inpatient
  • Aseptic: Outpatient

ONGOING CARE

  • Monitoring:
  • Septic: WBC, cultures, adjust antibiotics
  • Aseptic: Monitor symptoms, consider D-dimer for resolution, follow-up only if not resolving
  • Education:
  • Local care, elevation, compression, risk/recurrence, signs of progression, follow-up for thrombophilia/migratory cases

PROGNOSIS

  • Septic: High mortality (50%) if untreated; prognosis depends on timing, surgery, infection
  • Aseptic: Usually benign, resolves in 2–3 weeks; recurrence if varicosities not removed or ongoing hypercoagulability

COMPLICATIONS

  • Septic: Sepsis, bacteremia, septic PE, metastatic abscess, pneumonia, subperiosteal abscess (children)
  • Aseptic: DVT, VTE, embolic events

REFERENCES

  1. Nasr H, Scriven JM. BMJ. 2015;350:h2039.
  2. Beyer-Westendorf J, et al. Lancet Haematol. 2017;4(3):e105-e113.
  3. Di Nisio M, et al. Cochrane Database Syst Rev. 2018;2(2):CD004982.
  4. Decousus H, et al. N Engl J Med. 2010;363(13):1222-1232.

ICD-10 CODES

  • I80.9: Phlebitis/thrombophlebitis, unspecified site
  • I80.00: Superficial vessels, lower extremity
  • I80.8: Other sites

CLINICAL PEARLS

  • Mild cases are typically self-limited and respond well to conservative care.
  • High-risk superficial thrombophlebitis needs anticoagulation.
  • Proximal/large vein involvement benefits from anticoagulation to prevent DVT.
  • Septic thrombophlebitis: admit for antibiotics, anticoagulation; surgery for severe cases.