> Table of Contents > Superficial Thrombophlebitis
Superficial Thrombophlebitis
Emily M. Culliney, MD, FAAFP
image BASICS
DESCRIPTION
  • Superficial thrombophlebitis is venous inflammation with secondary thrombosis of a superficial vein.
  • Most common in the lower extremities (60-80%), but can occur in the upper extremities/neck.
  • Generally a benign and self-limiting process, but can be painful
  • Traumatic thrombophlebitis types:
    • Injury
    • IV catheter related
    • Intentional (i.e., sclerotherapy)
  • Aseptic thrombophlebitis types:
    • Primary hypercoagulable states: disorders with measurable defects in the proteins of the coagulation and/or fibrinolytic systems
    • Secondary hypercoagulable states: clinical conditions with a risk of thrombosis (venous stasis, pregnancy)
  • Septic (suppurative) thrombophlebitis types:
    • Iatrogenic, long-term IV catheter use
    • Infectious, mainly syphilis and psittacosis
  • Mondor disease
    • Rare presentation of anterior chest/breast veins of women
  • System(s) affected: cardiovascular
  • Synonym(s): phlebitis; phlebothrombosis
Geriatric Considerations
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
    • Behçet, 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.
image DIAGNOSIS
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)
  • P.1003

  • 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.
image 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
image 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
REFERENCES
1. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2013;(4):CD004982.
2. 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.
3. Di Nisio M, Middeldorp S. Treatment of lower extremity superficial thrombophlebitis. JAMA. 2014;311(7):729-730.
Additional Reading
&NA;
  • Decousus H, Leizorovicz A. Superficial thrombophlebitis of the legs: still a lot to learn. J Thromb Haemost. 2005;3(6):1149-1151.
  • Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med. 2010;152(4):218-224.
  • Wichers IM, Di Nisio M, Büller 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.
See Also
&NA;
Deep Vein Thrombophlebitis
Codes
&NA;
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
Clinical Pearls
&NA;
  • Mild superficial thrombophlebitis is typically selflimiting 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.