Superficial Thrombophlebitis
Superficial thrombophlebitis is an inflammatory condition of superficial veins characterized by thrombosis with associated inflammation, presenting with localized pain, erythema, tenderness, and often a palpable cord along the affected vein. 1, 2
Definition and Pathophysiology
Superficial thrombophlebitis (SVT), also known as superficial venous thrombosis, involves clotting of veins just beneath the skin surface with accompanying inflammatory changes. It differs from deep vein thrombosis (DVT) in several important ways:
- Occurs in superficial venous system rather than deep veins
- Generally has less severe clinical implications than DVT
- Presents with visible and palpable signs of inflammation
- May be associated with or progress to DVT in some cases 1, 3
Two distinct forms exist:
- Varicose vein thrombophlebitis - characterized by large thrombus in a varicose vein with modest surrounding inflammation
- Non-varicose vein thrombophlebitis - affects normal veins with intima proliferation and media fibrosis 4
Clinical Presentation
SVT typically presents with:
- Pain and tenderness along the affected vein
- Erythema and warmth over the involved area
- Induration and a palpable cord-like structure
- Local swelling 1
Unlike DVT, SVT is more likely to be symptomatic and visible, especially when occurring in the lower extremities 1.
Risk Factors
Common risk factors include:
- Venous valvular insufficiency
- Varicose veins
- Pregnancy
- Recent trauma or venipuncture
- Intravenous catheters (peripheral or central)
- Infection
- Prothrombotic conditions (including malignancy)
- Thrombophilia 2, 5
Diagnosis
Diagnosis is primarily clinical, based on characteristic symptoms and physical examination findings:
- Tenderness, erythema, and/or an indurated cord associated with a superficial vein
- Negative ultrasound finding for DVT 1
Duplex ultrasound is recommended to:
- Confirm the diagnosis
- Evaluate the extent of thrombus
- Assess proximity to deep venous system
- Rule out concurrent DVT 3
Complications and Prognosis
While generally self-limited, SVT can lead to serious complications:
- Extension into the deep venous system (particularly when located near the saphenofemoral junction)
- Development of DVT (reported in 6-53% of cases)
- Pulmonary embolism (reported in 0-33% of cases) 4, 6
In cancer patients, SVT may be associated with Trousseau's syndrome, characterized by migratory thrombophlebitis, warfarin resistance, thrombocytopenia, and chronic disseminated intravascular coagulation 1.
Management
Treatment depends on the location, extent, and risk factors:
Conservative measures for uncomplicated SVT:
Pharmacological therapy:
- For SVT >5 cm: Fondaparinux 2.5 mg daily or LMWH for 45 days
- For SVT >5 cm or above knee: Prophylactic dose anticoagulation for at least 6 weeks
- For SVT within 3 cm of saphenofemoral junction: Therapeutic dose anticoagulation for at least 3 months 3
Topical treatments:
Catheter-associated SVT:
Surgical interventions (for refractory cases):
- Phlebectomy
- Sclerotherapy
- Saphenous junction ligation
- Saphenous vein stripping 2
Follow-up and Monitoring
- Repeat ultrasound in 7-10 days if symptoms are not improving
- More frequent monitoring for patients with risk factors (active cancer, history of VTE, obesity, thrombophilia)
- Assess for progression to DVT if symptoms worsen 3
Special Considerations
- Upper extremity SVT may be associated with thoracic outlet syndrome, malignancy, or hypercoagulable states that require specific treatment 3
- SVT in cancer patients may require more aggressive anticoagulation 1, 3
- Migratory thrombophlebitis should raise suspicion for Trousseau's syndrome or underlying malignancy 1
- Different clinicopathological presentations may correlate with specific underlying conditions - elongated nodules with pure thrombosis suggest malignancy or thrombophilia, while panniculitis-like lesions may indicate Behçet's disease 5