Do we need a consensus on diagnostic and treatment of superficial thrombophlebitis? Viera Stvrtinova II.nd Clinic of Internal Medicine II.nd Clinic of

Do we need a consensus on Do we need a consensus on diagnostic and treatment diagnostic and treatment

of superficial of superficial thrombophlebitis?thrombophlebitis?Viera StvrtinovaViera Stvrtinova II.nd Clinic of Internal Medicine II.nd Clinic of Internal Medicine

Medical Faculty Comenius UniversityMedical Faculty Comenius UniversityBRATISLAVA, Slovak republicBRATISLAVA, Slovak republic

18th Congress of the European Chapter ot the IUA, PALERMO, October 2009

INTRODUCTIONINTRODUCTION

• Traditionally ST has been considered a relatively benign and limited disease or sign of chronic venous insufficiency

• In recent years it seems that ST is not such a banal condition

• Some physicians consider ST an integral part of venous thromboembolism, together with DVT and PE

ST and VTEST and VTE

• Association between ST and DVT vary in the literature from 6 to 53% and pulmonary embolism up to 33%

• The relationship between ST and DVT is supported also by the same risk factors that triggers ST as well as DVT.

in ST a DVT – in ST a DVT – always always

other part of other part of Virchow´s Virchow´s

triad triad is is more important more important

Rudolf VIRCHOW

(1821-1902)

RISK FACTORS for STRISK FACTORS for ST

•Slowing of the blood flowSlowing of the blood flow• Varicose veinsVaricose veins• Prolonged bed rest (immobilization) Prolonged bed rest (immobilization)

for several reasons (operation, for several reasons (operation, trauma, serious infection, heart trauma, serious infection, heart failure, pulmonary emphysema, etc.)failure, pulmonary emphysema, etc.)


•Coagulation disordersCoagulation disorders• Thrombophilia – Factor V Leiden Thrombophilia – Factor V Leiden

mutation, protein C deficiency, mutation, protein C deficiency, protein S deficiency, AT III deficiency, protein S deficiency, AT III deficiency, prothrombin G20210A mutation, etcprothrombin G20210A mutation, etc

• CancerCancer• PregnancyPregnancy• Oral contraceptivesOral contraceptives• Anti-phospholipid syAnti-phospholipid sy


•Damage of the venous Damage of the venous wallwall

• Intravenous injectionsIntravenous injections• Intravenous cathetersIntravenous catheters• Injury, traumaInjury, trauma• Varicose veins and chronic venous Varicose veins and chronic venous

insufficiencyinsufficiency


•Other risk factors and Other risk factors and diseasesdiseases

• Winiwarter-Buerger´s diseaseWiniwarter-Buerger´s disease• Behcet´s diseaseBehcet´s disease• Other chronic inflammatory Other chronic inflammatory

autoimmune diseasesautoimmune diseases• ObesityObesity• Age (over 60 yrs) Age (over 60 yrs)

ST - incidenceST - incidence• ST is a frequent disease, but its exact

incidence is not known. • The incidence of ST could be around

400 cases in 100.000 person – years according to UK estimates

• It is depending on the age of the population, on the used investigation method (clinical dg. or DUS), and the fact, that ST is mostly managed on GPs level

ST - ClassificationST - ClassificationAccording the etiology:According the etiology: 1.PRIMARY ST1.PRIMARY ST (inflammation affects only (inflammation affects only the venous wall and surrounding peri-the venous wall and surrounding peri-venous tissue) venous tissue) 2.SECONDARY ST2.SECONDARY ST (inflammation (inflammation of the venous wall is associated with of the venous wall is associated with other inflammatory process or systemic other inflammatory process or systemic disease in the bodydisease in the body

Primary STPrimary ST

1. varicophlebitis1. varicophlebitis

2. septic catheter´s ST (e.g. non 2. septic catheter´s ST (e.g. non sterile i.v. injections in drug abusers, sterile i.v. injections in drug abusers, i.v.catheters in patients with i.v.catheters in patients with immunodeficiency )immunodeficiency )

3. “sterile” ST due to intravenous 3. “sterile” ST due to intravenous drug administration (scleroterapy) drug administration (scleroterapy)

4. Mondor thrombophlebitis4. Mondor thrombophlebitis

Secondary STSecondary ST

1. Winiwarter – Buerger´s disease1. Winiwarter – Buerger´s disease

2. Behcet´s disease2. Behcet´s disease

3. other vasculitic or chronic 3. other vasculitic or chronic rheumatic syndromes with rheumatic syndromes with autoimmune etiology (e.g.anti-autoimmune etiology (e.g.anti-phospolipid syndrome)phospolipid syndrome)

4. malignant tumors4. malignant tumors

FORMS of STFORMS of ST

1.varicophlebitis 1.varicophlebitis – – ST of a varicose ST of a varicose vein (VST)vein (VST)

22. ST on a healthy, non-varicose . ST on a healthy, non-varicose superficial vein – superficial vein – non-varicose ST non-varicose ST (NVST) (NVST)

88% of ST88% of STare VSTare VST

Endothelial injury in NVST

Circulatory stasis Circulatory stasis in in varicophlebitis

always other part of Virchow´s always other part of Virchow´s triad is more importanttriad is more important

Varicophlebitis and DVTVaricophlebitis and DVT In a retrospective study of 114 In a retrospective study of 114

patients with ST the incidence of a patients with ST the incidence of a concomitant DVT was 15.6% when ST concomitant DVT was 15.6% when ST affected the vena saphena magna or affected the vena saphena magna or vena saphena parva, but only 5.2% vena saphena parva, but only 5.2% when side branches were involved. when side branches were involved.

With varicose veins as a single risk With varicose veins as a single risk factor, the frequency of a concomitant factor, the frequency of a concomitant DVT was 6%, varicose veins combined DVT was 6%, varicose veins combined with further risk factorswith further risk factors showed a DVT showed a DVT frequency of 15.4%frequency of 15.4% (Noppeney et al, 2006).(Noppeney et al, 2006).

NVSTNVST (“non-varicose” (“non-varicose” superficial thrombophlebitis)superficial thrombophlebitis)

• is a miscellaneous group of disorders, where inflammation is a dominating feature in some conditions, while thrombosis dominates in other cases.

• Among 2319 patients diagnosed with Behcet´s disease ST was present in 53.3% and DVT in 29,8% of cases

ST in Winiwarter´s – Buerger´s dis.ST in Winiwarter´s – Buerger´s dis.

• ST in Buerger´s disease belongs to the diagnostic criteria

• Thrombophlebitis migrans (inflammation of the venous wall goes up or down – proximally or distally on a superficial vein) or thrombophlebitis saltans (inflammation “jumps” from one vein to another vein) are specific forms of ST often seen in patients with Winiwarter-Buerger´s disease.

NVSTNVST• In a prospective analysis of 42 patients

with non varicose ST investigation for risk factors revealed a neoplasm in 2 patients (4.8%), a non neoplasic systemic disease in 4 (9.5%) a thrombophilic condition in 20 patients (48%).

• The most frequent thrombophilia was the heterozygous mutation of coagulation factor V Leiden – (Gillet et al, 2004).

ST diagnosisST diagnosis

• In many cases ST is a banal condition, which resolves spontaneously, but in recent years due to systematic ultrasound investigation of the venous system a large number of deep venous thromboses concomitant with ST has been revealed.

ThrombophlebitisThrombophlebitis

DUS

ST treatmentST treatmentOn contrary to the treatment of deep venous On contrary to the treatment of deep venous thrombosis, only little is known about the thrombosis, only little is known about the most appropriate management of ST.most appropriate management of ST.

ST is etiologically a heterogeneous group of ST is etiologically a heterogeneous group of disorders with a different degree of disorders with a different degree of inflammation and thrombosisinflammation and thrombosis

the main etiological factor and contribution of the main etiological factor and contribution of different risk factors always should be different risk factors always should be considered before treatment decision. considered before treatment decision.

ST th. – ST th. – compressioncompression,, mobilizationmobilization

The main therapeutic procedure in all The main therapeutic procedure in all types of ST is compression and types of ST is compression and mobilization.mobilization.

There have been no randomized studies There have been no randomized studies demonstrating the effectiveness of demonstrating the effectiveness of compression, although this approach is compression, although this approach is considered by all experts to be essential. considered by all experts to be essential.

In all cases of ST immediate mobilization In all cases of ST immediate mobilization with elastic compression is necessary. with elastic compression is necessary.

All patients with All patients with ST sST should be treated hould be treated with compression therapy.with compression therapy.

RegulRegular walking supports the ar walking supports the effectiveness of the compression effectiveness of the compression bandagebandage on the on the LLLL. The patient must . The patient must walk regularly throughout the day and walk regularly throughout the day and avoid prolonged periods of being seated avoid prolonged periods of being seated or standing. or standing. Confinement to bed would Confinement to bed would favor progression of the thrombus in favor progression of the thrombus in both the superficial and the deep both the superficial and the deep venous systemvenous system

ST treatment - DRUGSST treatment - DRUGSAnticoagulants Anticoagulants Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory drugsdrugs (NSAIDs)(NSAIDs) Topical local anti-inflammatory Topical local anti-inflammatory treatmenttreatment (gel, cream, spray)(gel, cream, spray) Venoactive drugsVenoactive drugs – – in patients in patients with varicose STwith varicose ST AntibioticsAntibiotics – in patients with – in patients with septic STseptic ST CorticosteroidsCorticosteroids – – in patients with in patients with vasculitic and autoimmune vasculitic and autoimmune syndromessyndromes

ST treatment - ST treatment - anticoagulantsanticoagulants

Especially in cases of extensive ST Especially in cases of extensive ST anticoagulant therapy is a good choice. anticoagulant therapy is a good choice. LWMH, UFH as well as oral LWMH, UFH as well as oral anticoagulants are used in prophylactic anticoagulants are used in prophylactic as well as therapeutic doses.as well as therapeutic doses.

Not only the doses, but the duration of Not only the doses, but the duration of the treatment is different in individual the treatment is different in individual hospitals and medical care centers. hospitals and medical care centers.

LMWH and STLMWH and ST

? ? ? ? ? ? ?? ? ? ? ? ? ?Dosage – prophylactic or therapeuticDosage – prophylactic or therapeutic

Duration – 10, 20, 30 days ????????Duration – 10, 20, 30 days ????????

Proposal for ST Proposal for ST management management from CEVF from CEVF

Recommendation n.1:Recommendation n.1:

In every patient with NVST and in In every patient with NVST and in every patient with recurrent VST look every patient with recurrent VST look carefully for risk factors for carefully for risk factors for superficial thrombophlebitis, superficial thrombophlebitis, especially for thrombophilia and especially for thrombophilia and cancercancer



Clinical investigation may the real Clinical investigation may the real extent of superficial thrombophlebitis extent of superficial thrombophlebitis underestimate, and does not give underestimate, and does not give enough information on the status of enough information on the status of deep venous system, therefore after deep venous system, therefore after clinical investigation it is important to clinical investigation it is important to perform duplex ultrasound perform duplex ultrasound investigation of the superficial and investigation of the superficial and deep venous system, too.deep venous system, too.18th Congress of the European Chapter ot the IUA, PALERMO, October 2009


Duplex ultrasound investigation Duplex ultrasound investigation should be done bilaterally - on both should be done bilaterally - on both lower limbs, not only on the limb lower limbs, not only on the limb affected with ST.affected with ST.


It is necessary It is necessary (mandatory) (mandatory) to perform to perform duplex ultrasound investigation duplex ultrasound investigation immediately after clinical diagnosis of immediately after clinical diagnosis of ST in the case of ST localized on the ST in the case of ST localized on the trunk of the great saphenous vein 10 trunk of the great saphenous vein 10 cm and less from the sapheno-femoral cm and less from the sapheno-femoral junction or on the trunk of small junction or on the trunk of small saphenous vein 10 cm or less from the saphenous vein 10 cm or less from the sapheno-popliteal junction.sapheno-popliteal junction.



Recommendation n.5:Recommendation n.5:All patients with superficial All patients with superficial thrombophlebitis should be treated thrombophlebitis should be treated with compression therapy.with compression therapy.Recommendation n.6:Recommendation n.6:In all cases of ST immediate In all cases of ST immediate mobilization with elastic compression mobilization with elastic compression is necessary (mandatory). Patients is necessary (mandatory). Patients should not be confined to bed.should not be confined to bed.

Proposal forProposal forST management ST management from from CEVFCEVF


Patients with ST, with an inflamed and Patients with ST, with an inflamed and thrombosed superficial vein longer thanthrombosed superficial vein longer than 5 cm in duplex ultrasound 5 cm in duplex ultrasound investigation should have anticoagulant investigation should have anticoagulant treatment with LMWH for 4 weeks. The treatment with LMWH for 4 weeks. The dosage and duration of anticoagulation dosage and duration of anticoagulation depends on the concomitant diseases depends on the concomitant diseases and other risk factors for VTE. and other risk factors for VTE.

Recommendation Recommendation n.7:n.7:


In conclusionIn conclusion

Do we need a consensus on Do we need a consensus on diagnostic and treatment of diagnostic and treatment of superficial thrombophlebitis?superficial thrombophlebitis?

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Do we need a consensus on diagnostic and treatment of superficial thrombophlebitis? Viera Stvrtinova II.nd Clinic of Internal Medicine II.nd Clinic of