From the Guidelines
Therapeutic anticoagulation is recommended for saphenous vein thrombosis within 2.3 cm of the saphenofemoral junction due to the high risk of extension into the deep venous system. This approach is supported by the most recent guidelines, including the 2024 NCCN Clinical Practice Guidelines in Oncology, which suggest that therapeutic dose anticoagulation should be considered if the clot is in close proximity (defined as within approximately 3 cm) to the deep venous system 1.
Treatment Options
The treatment typically involves a direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban. Specifically, rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily for a total of 3 months, or apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily for the remainder of the 3-month period, can be used. Alternatively, low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily can be used, potentially transitioning to warfarin with a target INR of 2-3.
Additional Measures
Compression therapy with 30-40 mmHg graduated compression stockings should be used concurrently to reduce symptoms and prevent post-thrombotic syndrome. Regular follow-up with duplex ultrasound is necessary at 1-2 weeks after diagnosis to ensure the thrombus is not extending. Patients should be monitored for signs of pulmonary embolism including shortness of breath, chest pain, or hemoptysis.
Rationale
This aggressive treatment approach is warranted because superficial vein thrombosis located this close to the saphenofemoral junction has a significant risk of progressing to deep vein thrombosis or pulmonary embolism if left untreated with anticoagulation, as highlighted in the guidelines and studies such as the SURPRISE trial 1 and the executive summary of antithrombotic therapy for VTE disease 1. The use of anticoagulation for 45 days or more is suggested for patients with SVT at increased risk of clot progression to DVT or PE, with fondaparinux or rivaroxaban being reasonable options 1.
From the Research
Treatment of Saphenous Vein Thrombosis
- The treatment of saphenous vein thrombosis within 2.3 cm of the saphenofemoral junction is crucial to prevent complications such as thrombus propagation, recurrence, and venous thromboembolism (VTE) 2, 3.
- Anticoagulation has become the treatment of choice for extensive acute superficial vein thrombosis (SVT) in the great saphenous vein (GSV) to prevent future thromboembolic events 2.
- Low-molecular-weight heparin (LMWH) is associated with a lower rate of thrombus extension and subsequent recurrence, especially when an intermediate dose is used for a period of 30 days 2.
- Prophylactic doses of fondaparinux, a factor Xa inhibitor, have been found to be beneficial in reducing the rate of thrombus extension and recurrence as well as in reducing the risk of subsequent VTE 2.
- The proximity of the thrombus to the saphenofemoral junction (SFJ) is an important factor, with thrombi within 5 cm of the SFJ being associated with an increased rate of pulmonary embolism (PE) 3.
Management Strategies
- Management of isolated great saphenous vein thrombus (GSVT) is heterogeneous, and the type of treatment does not seem to affect outcomes 3.
- Anticoagulation, compression, and deep venous system (DVS) saline flushing are some of the management strategies used for GSVT 4.
- Five days of postprocedural oral apixaban anticoagulation has been shown to significantly decrease the occurrence of deep vein thrombosis (DVT) after great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena) 4.
- The duration of antithrombotic therapy is an important consideration, with shorter durations (3-6 months) being more beneficial for the primary treatment of venous thromboembolism (VTE) and indefinite antithrombotic treatment being more beneficial for the secondary prevention of unprovoked VTE or VTE provoked by chronic risk factors 5.