Transcript antignani_superficial thrombophlebitis

Palermo 2009
SUPERFICIAL THROMBOPHLEBITIS
Diagnostic criteria
P.L. Antignani - C. Allegra
Dept. of Angiology, S. Giovanni Hospital,
Rome, Italy
“Superficial thrombophlebitis is a common and benign
disease”.
“When large population of patients with superficial
venous thrombosis are studied, the association with
deep vein thrombosis appears rather small.
Thus systematic screening for deep vein thrombosis may
not be warratened in the presence of superficial venous
thrombosis unless additional risk factors are present
(es. immobilitation) ”.
Bounameaux H, Reber-Wesem MA: Arch Int Med 1997;157:1822-24
Today is different !

Superficial Venous Thrombosis (SVT)
on healthy veins

Superficial venous thrombosis on
varicose veins
Factors causing superficial venous thrombosis
A blow, fracture, or other injury to the leg or directly on the vein.
Prolonged bed rest, especially after surgery (which causes the blood to "pool"
in the legs).
Prolonged inactivity such as sitting in one position for extended periods of
time (as on long car, train, or plane trips).
Pregnancy
Obesity
Cancer
Systemic autoimmune disorders (Behçet)
Buerger’s disease
Congenital thrombophilic conditions
Varicose veins
Physical examination
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In each type of superficial thrombophlebitis, the
condition presents as redness and tenderness along the
course of the vein, usually accompanied by swelling.

Bleeding also can occur at the site of a varicose vein.
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Although unusual, it may occur in the small saphenous
vein, which empties into the popliteal vein.

Superficial thrombophlebitis of the upper extremities
usually occurs at infusion sites or sites of trauma.
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Superficial thrombophlebitis can occur in the external
jugular vein if it has been used for an infusion site.
Superficial venous thrombosis
Healthy vein
Abundant intima proliferation and media
fibrosis with non-important thrombosis are
the hallmark of this form which may be
associated with a systemic disease.
Varicose vein
It is characterized by a large thrombus in a
varicose vein and a modest inflammatory
process localized in the vessel surrounding
but not in its wall.
Traumatic and iatrogenic phlebitis
Superficial venous thrombosis following an injury usually occurs in an extremity,
manifesting as a tender cord along the course of a vein
juxtaposing the area of trauma.
Ecchymosis may be present early in the disease, indicating
extravasation of blood associated with injury to the vein,
and this may turn to brownish pigmentation over the vein as
the inflammation resolves.
Thrombophlebitis frequently occurs at the site of an intravenous infusion and is the
result of irritating drugs, hypertonic solutions, or the intraluminal catheter or
cannula itself. This is by far the most common type of thrombophlebitis encountered.
Usually, redness and pain signal its presence while the infusion is being given, but
thrombosis may manifest as a small lump days or weeks after the infusion apparatus
has been removed. It may take months to completely resolve.
The features of the iatrogenic form of traumatic (chemical) phlebitis may be
deliberately produced by sclerotherapy.
Phlebitis as the result of an infection
In 1932, DeTakats suggested that dormant infection in varicose veins was a
factor in the development of thrombophlebitis occurring at operation or
after injection treatments, trauma, or exposure to radiation therapy.
Altemeier and colleagues suggested that the presence of L-forms and other
atypical bacterial forms in the blood may play an important etiologic role in
the disease and recommended administration of tetracycline.
Septic phlebitis usually occurs in association with the long-term use of an
intravenous cannula inserted for the administration of fluid or medications.
Suppurative thrombophlebitis is a more serious, even lethal, complication of
intravenous cannulation and therapy and is characterized by purulence within
the vein. It frequently is associated with septicemia.
Aerobic and anaerobic as well as mixed infections have been related to
superficial venous thrombosis. Aerobic organisms include Staphylococcus
aureus, Pseudomonas, and Klebsiella; anaerobic bacteria include
Peptostreptococcus, Propionibacterium, Bacteroides fragilis, and more
recently, fungi.
Migratory phlebitis
Jadioux first described migratory thrombophlebitis in 1845 as an
entity characterized by repeated thromboses developing in
superficial veins at varying sites but most commonly in the lower
extremity.
Although numerous etiologic factors have been proposed, none has
been confirmed.
The association of carcinoma was first reported by Trousseau in
1856. Sproul noted migratory thrombophlebitis to be especially
prevalent with carcinoma of the tail of the pancreas (50 %).
Phlebitis occurs in diseases associated with vasculitis, such as
polyarteritis nodosa (periarteritis nodosa) and Buerger disease.
Buerger noted phlebitis in 8 of 19 patients, and Shionoya reported it
in 43% of the 255 patients he followed.
Mondor’s Disease
Thrombophlebitis of the superficial veins
of the breast and the anterior chest wall
Mondor disease is a rare condition.
The thrombophlebitis is usually located in the
anterolateral aspect of the upper portion of the
breast or in the region extending from the lower
portion of the breast across the submammary fold
toward the costal margin and the epigastrium.
A characteristic finding is a tender cordlike
structure that may be demonstrated best by
tensing the skin by elevating the arm.
The cause is unknown, but a search for malignancy is indicated.
Mondor disease occurs after recurrent local trauma, breast surgery,
with the use of oral contraceptives, and with a protein C deficiency.
Thrombosis in a varicose vein
Superficial venous thrombosis frequently occurs in varicose veins.
It may extend up and down the saphenous vein or may remain confined
to a cluster of tributary varicosities away from the main saphenous
vein.
Superficial thrombosis along the course of the greater saphenous vein
is observed more often to progress to the deep system.
Although it may follow trauma to a varix, it often appears to occur
without antecedent cause.
Thrombosis develops as a tender hard knot in a previously noted
varicose vein and is frequently surrounded by erythema.
At times, bleeding may occur as the reaction extends through the vein
wall.
It frequently is observed in varicose veins surrounding venous stasis
ulcers.
Main rule
In the absence of varicose veins one
should look for other reasons such as:
-
Malignancy elsewhere in the body,
Autoimmune diseases,
Buerger's disease,
An inherited tendency to clot
Differential Diagnoses
Cellulitis
Lymphangitis
Neuritis
Ruptured medial head of the gastrocnemius
Tendonitis
Diagnostic criteria
Patients who present with spontaneous superficial
thrombosis without a previous indwelling intravenous
catheter or other precipitating cause should be
considered for evaluation for a hypercoagulable state.
All patients with a past history of another
thromboembolic event should undergo a workup.
Evaluation should include tests for factor V Leiden and
prothrombin gene mutations, protein C and protein S,
antithrombin C, factor VIII, antiphospholipid
antibodies, lupus anticoagulant and homocysteine.
Diagnostic criteria
Schonauer et al reported a high factor VIII
concentration to be an independent risk factor for
recurrent superficial thrombosis after another episode
of venous thromboembolism.
De Godoy and Braile reported that 5.5% of patients with
repetitive superficial venous thrombosis were positive
for protein S deficiency.
Other authors have reported that both factor V Leiden
and the prothrombin gene mutation significantly
increases the risk of superficial venous thrombosis.
Superficial venous thrombosis and hypercoagulable states
L. Leon. Eur. J. Vasc.En. Surg. Jan 2005
Diagnostic criteria
Migratory thrombophlebitis, especially without
good cause, may be an indication for a more
detailed evaluation of the patient in search of
a malignant lesion.
This also should include selective application of
CT scans, mammography, colonscopy, serum
carcinoembryonic antigen (CEA) and prostatespecific antigen (PSA).
Prevalence and investigation
Data for prevalence vary greatly:
6-53% for coexistence,
2.6-15% for propagation,
0-33% for (asymptomatic) PE
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Superficial venous thrombosis is diagnosed in
a clinical setting but ultrasonography is useful
to define the thrombosis and check for
concomitant DVT.
Imaging evaluation: ultrasound
Duplex ultrasound evaluation is the
diagnostic method of choice to
search for venous thrombosis.
Thrombosed veins may appear
thickened or inflamed on
ultrasound, but the most diagnostic
finding is a lack of compressibility
of the vein using the scan head.
An experienced ultrasound
technologist should be able to
diagnose superficial venous
thrombosis with a high sensitivity
and specificity.
Aims of a non invasive
evaluation
Show the existence of superficial
venous thrombosis
Differentiate the acute phase from the
residual thrombus
Define the characteristic of thrombus
Define if the vein is varicose or healthy
Imaging evaluation: ultrasound
• Study of the deep veins (coexistence of a DVT)
• Evaluation of the wall and of the lumen (differential diagnostic
between SVT on healthy vein and varicose one)
• Collaterals involved
• Extension of thrombosis and involvement of saphenous vein at upper
and lower knee and evaluation of not involved veins
• Study of the perforanting veins and their possible involvement
• Study of SF junctions and SP junctions with thrombosis extension
evaluation
• Thrombus characteristic
• Characteristic of the lumen if signs of past SVT are already present
• Signs of recanalization
Most important findings
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
Verify if the clot
is adherent to
wall or not
Evaluate his
extension to deep
venous system
We have to consider the SVT as DVT if the thrombus
is localized into 2 cm from SFJ or SPJ
Imaging evaluation: ultrasound
A key question concerns the location and extent of superficial thrombosis,
as well as the proximity to the deep venous system at the saphenofemoral
or saphenopopliteal junction.
Lutter and associates reported that 12% of 186 patients with superficial
thrombophlebitis of the great saphenous vein above the knee had
extension into the deep venous system.
In our case report the percentage is of 31,2 %.
It is manadtory to evaluate the presence of an associated deep vein
thrombosis in the ipsilateral as well as contralateral limb.
After an initial diagnosis of superficial venous thrombosis, especially in the
thigh region, a follow-up duplex ultrasound examination should be
performed to look for progression of disease after treatment is initiated.
A finding of no clot extension indicates successful therapy; thrombus
extension or encroachment toward the deep venous system should prompt
more aggressive treatment.
Venography
Venography is rarely required to diagnose a superficial
venous thrombosis.
It should generally be avoided because of the potential
complications of intravenous contrast administration,
which can itself lead to phlebitis.
Venography is not necessary to exclude the diagnosis of
deep vein thrombosis, which can be excluded with
duplex scanning.
If information on the pelvic veins or iliac venous outflow
tract is required, CT venography is usually preferable, if
available.
Complications
Extension into the deep venous system
Complications of suppurative phlebitis include the
following:
– Metastatic abscess formation
– Septicemia
Hyperpigmentation over the affected vein
Persistent firm nodule in subcutaneous tissues at
site of affected vein
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