How do you treat superficial thrombophlebitis?

Treatment of Superficial Thrombophlebitis

For superficial thrombophlebitis of the lower limb that is at least 5 cm in length, prophylactic anticoagulation with fondaparinux 2.5 mg daily or rivaroxaban 10 mg daily for 45 days is recommended. 1

Treatment Algorithm Based on Location and Severity

Extensive Superficial Thrombophlebitis (≥5 cm)

• Fondaparinux 2.5 mg daily for 45 days is the first-line treatment (Grade 2B recommendation) 2, 1, 3
• Alternative options if fondaparinux is unavailable:
  • Rivaroxaban 10 mg daily for 45 days 1
  • Prophylactic-dose low molecular weight heparin (LMWH) for 45 days (Grade 2C recommendation) 2, 3

Superficial Thrombophlebitis Near Saphenofemoral Junction

• If SVT is within 3 cm of the saphenofemoral junction, therapeutic dose anticoagulation for at least 3 months is recommended 1
• This location is treated similarly to proximal deep vein thrombosis due to high risk of progression 2, 1

Small Superficial Thrombophlebitis (<5 cm)

• For SVT less than 5 cm in length or below the knee:
  • Consider symptomatic treatment with warm compresses, NSAIDs for pain control, and elevation of the affected limb 1, 4
  • Consider repeat ultrasound in 7-10 days to assess for progression 1
  • If progression is found, initiate anticoagulation as described above 1

Benefits of Anticoagulation

• Anticoagulation reduces the risk of:
  • Progression to deep vein thrombosis (from 1.3% to 0.2%) 1, 3
  • Recurrent superficial vein thrombosis (from 1.6% to 0.3%) 1, 3
• A randomized trial showed that LMWH (dalteparin) was superior to ibuprofen in preventing extension of superficial thrombophlebitis during the 14-day treatment period 5

Special Considerations

Upper Extremity Superficial Thrombosis

• Superficial thrombosis of the cephalic and basilic veins generally does not require anticoagulant therapy 6
• Symptomatic treatment is usually sufficient 6

Catheter-Associated Superficial Thrombophlebitis

• If associated with a peripheral catheter that is no longer needed, remove the catheter 1
• If the catheter is still needed, it may not be necessary to remove it if the patient is treated with anticoagulation and/or symptoms resolve 1, 6

Pregnancy

• LMWH is recommended over fondaparinux in pregnant patients as fondaparinux crosses the placenta 1, 3
• Treatment should continue for the remainder of pregnancy and 6 weeks postpartum 3

Cancer Patients

• Follow the same anticoagulation recommendations as non-cancer patients 1
• Closer monitoring is warranted due to higher risk of progression 6

Diagnostic Approach

• Ultrasound imaging is essential to confirm SVT diagnosis and exclude concurrent deep vein thrombosis (DVT) 1, 3
• Approximately 25% of patients with SVT have underlying DVT 1, 3

Common Pitfalls to Avoid

• Failing to perform ultrasound to exclude concurrent DVT 3
• Inadequate duration of anticoagulation (45 days is recommended for extensive disease) 3
• Unnecessary bed rest, which can increase risk of DVT - ambulation with compression is preferred 4
• Relying solely on antibiotics, which are not indicated unless there is documented infection 4

Risk Factors for Progression to DVT

• SVT length greater than 5 cm 2, 1
• Location above the knee 1
• Proximity to deep venous system 2, 1
• History of venous thromboembolism (VTE) or SVT 1
• Active cancer 1, 6
• Recent surgery 1