Superficial Thrombophlebitis

para>Septic thrombophlebitis is more common; prognosis is poorer.
Pediatric Considerations

Subperiosteal abscesses of adjacent long bone may complicate the disorder.

Pregnancy Considerations

Associated with increased risk of aseptic superficial thrombophlebitis, especially during postpartum
NSAIDs are contraindicated during pregnancy.

EPIDEMIOLOGY

Predominant age
- Traumatic/IV related has no predominate age/sex.
- Aseptic primary hypercoagulable state
  - Childhood to young adult
Aseptic secondary hypercoagulable state
- Mondor disease: women, ages 21 to 55 years
- Thromboangiitis obliterans onset: ages 20 to 50 years
Predominant sex
- Suppurative: male = female
- Aseptic
  - Spontaneous formation: female (55 " 70%)
  - Mondor: female > male (2:1)

Incidence

Septic
- Incidence of catheter-related thrombophlebitis is 88/100,000 persons.
- Develops in 4 " 8% if cutdown is performed
Aseptic primary hypercoagulable state: antithrombin III and heparin cofactor II deficiency incidence is 50/100,000 persons.
Aseptic secondary hypercoagulable state
- In pregnancy, 49-fold increased incidence of phlebitis
- Superficial migratory thrombophlebitis in 27% of patients with thromboangiitis obliterans

Prevalence

Superficial thrombophlebitis is common.
1/3 of patients in a medical ICU develop thrombophlebitis that eventually progresses to the deep veins.

ETIOLOGY AND PATHOPHYSIOLOGY

Similar to deep venous thrombosis. Virchow triad of vessel trauma, stasis, and hypercoagulability (genetic, iatrogenic, or idiopathic)
Varicose veins play a primary role in etiology of lower extremity phlebitis
Mondor disease pathophysiology not completely understood
Less commonly due to infection (i.e., septic)
- Staphylococcus aureus, Pseudomonas, Klebsiella, Peptostreptococcus sp.
- Candida sp.
Aseptic primary hypercoagulable state
- Due to inherited disorders of hypercoagulability
Aseptic secondary hypercoagulable states
- Malignancy (Trousseau syndrome: recurrent migratory thrombophlebitis): most commonly seen in metastatic mucin or adenocarcinomas of the GI tract (pancreas, stomach, colon, and gallbladder), lung, prostate, and ovary
- Pregnancy
- Estrogen based oral contraceptives
- Beh §et, Buerger, or Mondor disease

Genetics
Not applicable other than hypercoagulable states

RISK FACTORS

Nonspecific
- Varicose veins
- Immobilization
- Obesity
- Advanced age
- Postoperative states
Traumatic/septic
- IV catheter (plastic > coated)
- Lower extremity IV catheter
- Cutdowns
- Cancer, debilitating diseases
- Burn patients
- AIDS
- IV drug use
Aseptic
- Pregnancy
- Estrogen-based oral contraceptives
- Surgery, trauma, infection
- Hypercoagulable state (i.e., factor V, protein C or S deficiency, others)
Thromboangiitis obliterans: persistent smoking
Mondor disease
- Breast cancer or breast surgery

GENERAL PREVENTION

Avoid lower extremity cannulations/IV.
Insert catheters under aseptic conditions, secure cannulas, and replace every 3 days.
Avoid stasis and use usual deep vein thrombosis (DVT) prophylaxis in high-risk patients (i.e., ICU, immobilized)

COMMONLY ASSOCIATED CONDITIONS

Frequently seen with concurrent DVT (6 " 53%)
Symptomatic pulmonary embolism can also be seen concurrently (0 " 10%)
Both DVT/PE can occur up to 3 months after onset of phlebitis.

DIAGNOSIS

HISTORY

Pain along the course of a vein

PHYSICAL EXAM

Swelling, tenderness, redness along the course of a vein or veins
May have a palpable cord along the course of the vein
May look like localized cellulitis or erythema nodosum
Fever in 70% of patients in septic phlebitis
Sign of systemic sepsis in 84% of suppurative cases

DIFFERENTIAL DIAGNOSIS

Cellulitis
DVT
Erythema nodosum
Cutaneous polyarteritis nodosa
Lymphangitis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)
Often none necessary if afebrile, otherwise healthy

Small or distal veins (i.e., forearms or below the knee): no recommended imaging
If concern for more proximal extension: venous Doppler US to assess extent of thrombosis and rule out DVT

Follow-Up Tests & Special Considerations

If suspicious for sepsis
- Blood cultures (bacteremia in 80 " 90%)
- Consider culture of the IV fluids being infused.
- CBC demonstrates leukocytosis.
Aseptic: evaluation for coagulopathy if recurrent or without another identifiable cause (e.g., protein C and S, lupus anticoagulant, anticardiolipin antibody, factor V and VIII, homocysteine)
In migratory thrombophlebitis, have a high index of suspicion for malignancy.
Repeat venous ultrasound to assess effectiveness of therapy.
- If thrombosis is extending, more aggressive therapy required.

Test Interpretation
The affected vein is enlarged, tortuous, and thickened with endothelial damage and necrosis.

TREATMENT

GENERAL MEASURES

Suppurative: consultation for urgent surgical venous excision
Local, mild
- Conservative management, antibiotics not useful
- For varicosities
  - Compression stockings, maintain activities
- Catheter/trauma associated
  - Immediately remove IV and culture tip.
  - Elevate with application of warm compresses.
  - If slow to resolve, consider LMWH.
Large, severe, or septic thrombophlebitis
- Inpatient care or bed rest with elevation and local warm compress
- When the patient is ambulating, then start compression stockings or Ace bandages.

MEDICATION

First Line

Best medication(s) and duration of treatment are not well-defined (1)[A].
Localized, mild thrombophlebitis (usually self-limited)
- NSAIDs and ASA for inflammation/pain to reduce symptoms and local progression .
- Use of compression stockings can also provide symptomatic relief (2).

Second Line

Septic/suppurative
- May present or be complicated by sepsis
- Requires IV antibiotics (broad spectrum initially) and anticoagulation
Increasing evidence shows that LMWH/fondaparinux treatment can prevent extension of superficial venous thrombosis in addition to VTE prevention.
Consider if thrombus present in the large veins or involving the long saphenous vein
- To prevent venous thromboembolism (VTE), 4 weeks of LMWH; such as enoxaparin
- 45 days of fondaparinux was found to reduce DVT and VTE by 85% (relative risk reduction) in one large study (3)[B].
Superficial thrombophlebitis related to inherited or acquired hypercoagulable states is addressed by treating the related disease.

ISSUES FOR REFERRAL

Severely inflamed or very large phlebitis should be evaluated for excision.

SURGERY/OTHER PROCEDURES

Septic
- Surgical consultation for excision of the involved vein segment and involved tributaries
- Drain contiguous abscesses.
- Remove all associated cannula and culture tips.
Aseptic: Manage underlying conditions.
- Evaluate for saphenous vein ligation to prevent deep vein extension after acute phase resolved.
- Consider referral for varicosity excision.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Septic: inpatient
Aseptic: outpatient

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Septic: routine WBC count and differential. Target treatment based on culture results.
Severe aseptic
- Repeat venous Doppler US in 1 to 2 weeks to ensure no DVT and assess treatment effectiveness: Do not expect resolution, just nonprogression.
- Repeat clotting studies.
Local, mild thrombophlebitis typically resolves with conservative therapy and does not require specific monitoring unless there is a failure to resolve.

DIET

No restrictions

PATIENT EDUCATION

Review local care, elevation, and use of compression hose for acute treatment and prevention of recurrence.

PROGNOSIS

Septic/suppurative
- High mortality (50%) if untreated
- Depends on treatment delay or need for surgery
Aseptic
- Usually benign course; recovery in 2 to 3 weeks
- Depends on development of DVT and early detection of complications
- Aseptic thrombophlebitis can be isolated, recurrent, or migratory.
- Recurrence likely if related to varicosity or if severely affected vein not removed

COMPLICATIONS

Septic: systemic sepsis, bacteremia (84%), septic pulmonary emboli (44%), metastatic abscess formation, pneumonia (44%), subperiosteal abscess of adjacent long bones in children
Aseptic: DVT (6 " 53%), VTE (up to 10%), thromboembolic phenomena

REFERENCES

11 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2013;(4):CD004982.22 Decousus H, Epinat M, Guillot K, et al. Superficial vein thrombosis: risk factors, diagnosis, and treatment. Curr Opin Pulm Med. 2003;9(5):393 " 397.33 Di Nisio M, Middeldorp S. Treatment of lower extremity superficial thrombophlebitis. JAMA. 2014;311(7):729 " 730.

ADDITIONAL READING

Decousus H, Quere I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med. 2010;152(4):218 " 224.
Decousus H, Leizorovicz A. Superficial thrombophlebitis of the legs: still a lot to learn. J Thromb Haemost. 2005;3(6):1149 " 1151.
Wichers IM, Di Nisio M, B Όller HR, et al. Treatment of superficial vein thrombosis to prevent deep vein thrombosis and pulmonary embolism: a systematic review. Haematologica. 2005;90(5):672 " 677.

CODES

ICD10

I80.9 Phlebitis and thrombophlebitis of unspecified site
I80.00 Phlbts and thombophlb of superfic vessels of unsp low extrm
I80.8 Phlebitis and thrombophlebitis of other sites
D68.59 Other primary thrombophilia
I80.03 Phlbts and thombophlb of superfic vessels of low extrm, bi
I80.01 Phlebitis and thombophlb of superfic vessels of r low extrem
D68.69 Other thrombophilia
I80.02 Phlebitis and thombophlb of superfic vessels of l low extrem

ICD9

451.9 Phlebitis and thrombophlebitis of unspecified site
451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.82 Phlebitis and thrombophlebitis of superficial veins of upper extremities
289.81 Primary hypercoagulable state
289.82 Secondary hypercoagulable state

SNOMED

2477008 Superficial thrombophlebitis (disorder)
40283005 Thrombophlebitis of superficial veins of lower extremity
95451004 Thrombophlebitis of superficial veins of upper extremities
439731006 Septic thrombophlebitis
76612001 Hypercoagulability state (finding)

CLINICAL PEARLS

Mild superficial thrombophlebitis is typically self-limiting and responds well to conservative care.
Lower extremity disease involving large veins or proximal saphenous vein may benefit from anticoagulation to prevent DVT.
Septic thrombophlebitis requires admission for antibiotics and anticoagulation. If severe, consider surgical consultation for venous excision.

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