Superficial venous

thrombophlebitis
Presented by - Nader Saad
 SVT is a self-limited process of
little consequence and of small
risk. *
Usually affects the lower limbs
Introduction
Often involving a varicose vein
CLINICAL
PRESENTATION

Erythema and tenderness in the

distribution of the superficial veins
Palpable cord.
Pain, erythema, and swelling are the
most common symptoms.
EPIDEMIOLOGY Incidence :Lower extremity SVT  3% -11% general
population

Increased prevalence of SVT in females (55-70%)

Increasing incidence with age ( Mean age = 60 years old )

Classification Occur in two forms: With/Without varicose veins

Primary SVT :
Most common in the saphenous veins and their tributaries,
followed by the upper extremity cephalic and basilic veins.
GSV (60% to 80%) , SSV (10% to 20%)
Patients with varicose veins are affected far more frequently
than in the general population (4% to 62%)
Secondary SVT :
Associated with systemic inflammatory conditions
Risk factors Virchow’s triad:
Endothelial injury  Trauma or insertion of venous
catheters
Venous stasis  Varicosities
Hypercoagulable states
Diagnosis and • SVT is a Clinical diagnosis
Duplex ultrasound may help with the diagnosis in equivocal
workup • Incompressible, dilated or varicose, superficial veins are
identified, lacking augmented luminal flow.
• Mapping the superficial and deep veins to characterize
superficial venous incompetence that can be treated
accordingly, after the acute phase.
• A WLUS, bilaterally , is required to rule out DVT
Superficial • The most common predisposing risk factor
• Manifest as tender nodules with localized induration and
Thrombophlebitis erythema.
With Varicose Veins • May remain localized to the cluster of tributary varicosities
or may extend into the GSV.
• Found in conjunction with venous stasis ulcers.
Other SVT types
Traumatic Thrombophlebitis :
Illicit drugs or undergoing drug therapy in a hospital or outpatient setting.
Cause: Endothelial injury from the intravenous catheter
Treatment: Cessation of the infusion/ Removal of the offending access
device/ Sometimes anticoagulation

Septic and Suppurative Thrombophlebitis

Association with septicemia.
Presentation:
Pus at an intravenous site, fever, leukocytosis, and local intense pain.
Treatment :
Removal of the foreign body and intravenous administration of antibiotics.
Migratory Thrombophlebitis

Defenition:
Repeated thrombosis developing in superficial veins at varying sites but most commonly in
the lower extremity.
Associated with carcinoma (Trousseau syndrome) and may precede diagnosis of the
carcinoma by several years.
Associated with systemic vasculopathies (Behçet disease, Buerger disease, PAN )

Diagnosis is made  Look for malignancy +++

Mondor Disease

Defenition:
Thoraco- epigastric vein of the breast and chest
wall thrombophlebitis
Benign and self-limited, and treatment is
conservative

Mondor disease:
SVT of the dorsal vein of the penis.
Treatment: NSAIDs and dorsal penile vein
resection if the symptoms are refractory.
SVT consequences / thromboembolic risks
• The main concern related to SVT is the likelihood that the thrombus will extend into the
deep veins.

Chengelis et al. followed 263 patients with isolated SVT and performed follow-up
ultrasound at 2 to 10 days
• 11% progression to DVT while not receiving anticoagulation.
• The most common site was propagation of the SVT in the GSV into the common femoral
vein.
 25% of patients with SVT already had extension
of thrombus to the deep venous system or PE at
the time of the initial diagnosis.
10% Developed thromboembolic complications
Prospective during the first three months of follow up
Observational
Superficial
Recurrence or extension 5%
Thrombophlebitis
(POST) study
A shorter duration of anticoagulation is
associated with a higher risk of recurrent events
in other studies
SVT consequences / thromboembolic risks
• Risk of thromboembolic events persists for the entire three months after SVT is
diagnosed
• Highest during the first month and gradually decrease.

The thromboembolic risk may be higher in subgroups :

1. Cancer
2. Extensive thrombosis(High level) affecting the GSV or at the popliteal fossa affecting
the small saphenous vein (SSV)
3. Near the junction with the deep venous system.
 Treatment

Background
The efficacy and safety of anticoagulant treatment for patients with acute, symptomatic superficial-vein thrombosis in the legs, but
without concomitant deep-vein thrombosis or symptomatic pulmonary embolism at presentation
Comparison of Arixtra in lower limb Superficial venous
thrombosis ( CALISTO)

• Methods
In a randomized, double-blind trial placebo controlled trial .
3002 patients SVT 5 cm to receive either fondaparinux, administered
subcutaneously at a dose of 2.5 mg once daily, or placebo for 45 days.
• Primary outcome:
Death , symptomatic pulmonary embolism, symptomatic deep-vein
thrombosis, or symptomatic extension to the saphenofemoral junction or
symptomatic recurrence at day .
 Baseline
characteristics
Comparison of Arixtra in lower limb Superficial venous thrombosis
( CALISTO)

Results :
• 85% reduction of venous thromboembolism in the fondaparinux group for 45 days
• Major bleeding occurred in one patient in each group.
• The incidence of serious adverse events was 0.7% with fondaparinux and 1.1% with placebo.
Conclusions :
• Fondaparinux at a dose of 2.5 mg once a day for 45 days was effective in the treatment of patients with
acute, symptomatic superficial-vein thrombosis of the legs and did not have serious side effects.
Antithrombotic treatment for superficial vein thrombosis

Intensity of anticoagulation :
Enoxaparin given in therapeutic or prophylactic doses for 12 days reduces the risk of SVT
recurrence and/or proximal extension

Duration of anticoagulation :
RCT indicated that an intermediate dose of parnaparin for 30 days is superior to either a 30
day prophylactic dose or a 10 day intermediate dose, considering that major bleeding was
not observed.
Antithrombotic treatment for superficial vein
thrombosis
• Factor Xa inhibitors in superficial vein thrombosis treatment:

• The SURPRISE investigators concluded that rivaroxaban was non- inferior to fondaparinux
for the treatment of SVT, was not associated with more major bleeding, and could offer
patients with symptomatic SVT an oral treatment option, which may be preferable to
subcutaneous injection.
• However, SVT is not a licensed indication for rivaroxaban at present and an RCT
comparing it with placebo was terminated because of slow recruitment rates.
TREATMENT OPTIONS ?
LMWH seems to provide the best outcomes for treatment of SVT with the least
complications.
However, questions remain regarding the duration of therapy, with 1 week likely
being too short.
• American College of Chest Physicians guidelines have not changed and give the
following recommendations for treatment of patients with SVT of the lower limb:
• 1. In those with SVT at least 5 cm in length, the use of a prophylactic dose of
fondaparinux or LMWH for 45 days is suggested over no anticoagulation (Grade
2B).
• 2. In those with SVT who are treated with anticoagulation, fondaparinux 2.5 mg
daily over a prophylactic dose of LMWH is suggested (Grade 2C).
Summary of recommendtions
Thank you