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Superficial vein thrombosis and phlebitis of the lower extremity veins

Superficial vein thrombosis and phlebitis of the lower extremity veins
Literature review current through: Jan 2024.
This topic last updated: Mar 15, 2023.

INTRODUCTION — Phlebitis and thrombosis of the lower extremity superficial veins is generally a benign, self-limited disorder; however, when the axial veins are involved (eg, great saphenous vein, accessory saphenous vein, small saphenous vein), thrombus propagation into the deep vein system (ie, deep vein thrombosis [DVT]) and even pulmonary embolism can occur [1,2]. Treatment is aimed at relieving local symptoms and preventing thromboembolic complications.

The clinical manifestations, diagnosis, and treatment of phlebitis and thrombosis of the lower extremity superficial veins are reviewed here. Phlebitis and thrombosis involving upper extremity veins most often occurs in the context of upper extremity venous cannulation and is discussed separately. Evaluation and treatment of patients with DVT is discussed separately. (See "Catheter-related upper extremity venous thrombosis in adults" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity" and "Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)".)

ANATOMY AND DEFINITIONS — The main axial superficial veins of the lower extremity are the great saphenous, anterior accessory saphenous, and small saphenous veins (table 1 and figure 1A-B). A source of ongoing confusion continues to be the occasional use of the abandoned term "superficial femoral vein" to describe the main deep vein in the thigh located adjacent the superficial femoral artery, and which is properly referred to as the "femoral vein" (figure 2) [3,4].

Definitions — The term phlebitis refers to the presence of inflammation within a vein, whereas thrombosis indicates the presence of clot within the vein [5]. In this review we will refer to the terminology surrounding this condition in the following manner:

Superficial phlebitis — The term superficial phlebitis denotes the presence of pain and inflammation involving a vein in the absence of thrombus. Superficial phlebitis is usually an initial clinical diagnosis, referring to the clinical findings of pain, tenderness, induration, and erythema along the course of a superficial vein. It is due to inflammation, and less commonly, with infection of the vein. If thrombus is apparent as a thickened cord or subsequently identified with imaging studies (often the case), the terms superficial thrombophlebitis or superficial vein thrombosis (SVT) are preferred.

Superficial thrombophlebitis — The more frequent use of duplex ultrasound has allowed the distinction of thrombophlebitis from phlebitis by confirming the presence or absence of thrombus within a vein. Although the term superficial thrombophlebitis can refer to any vein, in the lower extremity, we prefer to limit this term to the presence of symptoms of venous inflammation and confirmed thrombosis of the tributary veins, reserving the term SVT for inflammation and thrombosis of the axial veins (eg, great saphenous, accessory saphenous, and small saphenous veins).

Superficial vein thrombosis — The term "superficial vein thrombosis" has been adopted in the medical literature to connote a similar level of seriousness that is attached to the term "deep vein thrombosis" (DVT). This is due to the recognition that thrombosis of the axial veins (eg, great saphenous, anterior accessory saphenous, and small saphenous veins) can be associated with DVT and PE at the time of diagnosis or lead to subsequent thromboembolism, particularly when the more cephalad vein is affected. Although the phlebitis term is lacking here, the presence of symptoms of inflammation is understood, as these larger veins uncommonly thrombose without associated symptoms.

INCIDENCE — Thrombosis of the lower extremity superficial veins is relatively common and may be much more common than previously believed. In the past, phlebitis and thrombosis of the lower extremity superficial veins were diagnosed primarily on clinical grounds. With the more frequent use of duplex ultrasound, venous thrombosis is more readily identified. Thrombosis of the axial veins (ie, superficial vein thrombosis [SVT]) appears to be more prevalent than deep vein thrombosis (DVT) [6,7]. SVT more commonly involves the great saphenous vein compared with the small saphenous vein [8].

It is clear that a diagnosis of DVT increases the risk for thrombotic events, both at the time of initial diagnosis and subsequently. Whether a diagnosis of SVT of the lower extremity increases the risk for thrombotic events other than DVT or pulmonary embolism is uncertain [9,10]. In a cohort study from the Danish National Registry, the risk for acute myocardial infarction (AMI), stroke, and death was increased following a diagnosis of SVT over a median seven-year follow-up [9]. The highest risk was in the first three months following a diagnosis of SVT (AMI: hazard ratio [HR] 1.6, 95% CI 1.0-2.5; stroke: HR 2.6, 95% CI 1.8-3.8; death: HR 3.5, 95% CI 3.1-4.0).

RISK FACTORS — Thrombosis of the lower extremity superficial veins is associated with conditions that increase the risk of clotting, including those that lead to decreased venous flow and pooling, abnormalities of coagulation or fibrinolysis, and endothelial dysfunction. Venous hypertension can be due to acute venous disease (eg, deep vein thrombosis [DVT], vein injury), chronic venous disease (eg, varicose veins, chronic venous insufficiency), venous procedures (eg, sclerotherapy, surgical ablation, venipuncture), immobilization (eg, postoperative, trauma), pregnancy, obesity, infection, intravenous therapy, or drug abuse [11,12]. Risk factors for venous thrombosis are discussed in detail elsewhere. The most common factors associated with lower extremity SVT and superficial thrombophlebitis are briefly discussed below. (See "Overview of the causes of venous thrombosis", section on 'Superficial vein thrombosis'.)

Varicose veins – Phlebitis and thrombosis of the lower extremity superficial veins is most likely to occur in varicose veins [13]. Varicose veins account for etiology of the thrombosis in up to 90 percent of cases [14]. Risk factors for superficial thrombophlebitis among those with varicose veins include trauma to the abnormal veins and lack of physical activity.

Vein excision/ablation – Thrombosis and inflammation of the superficial veins of the lower extremity can develop following open surgical, chemical, or endovenous ablation of incompetent veins. Following open vein excision, the residual end of an avulsed vein segment undergoes spasm and thrombosis. Thrombus may extend retrograde into an adjacent patent vein. (See "Approach to treating symptomatic superficial venous insufficiency", section on 'Ambulatory phlebectomy'.)

Following endovenous ablation (eg, radiofrequency ablation, endovenous laser ablation, endovenous chemical adhesive ablation, sclerotherapy), treatment of the vein segment leads to inflammation, thrombosis, and fibrosis of the lumen. For some patients, SVT can occur in the treated segment if the amount of energy delivered was not adequate, or potentially above the treated segment when there is stasis. Varying degrees of pain and inflammation occur depending upon the device used to affect closure.

(See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins", section on 'Thrombus'.)

(See "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease", section on 'Endovenous heat-induced thrombus'.)

(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Endovenous heat-induced thrombus'.)

(See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Venous thromboembolism'.)

A comparison of the available methods for venous ablation is provided separately. (See "Comparison of methods for endovenous ablation for chronic venous disease".)

Pregnancy and estrogen therapy – The incidence of phlebitis and thrombosis of the lower extremity superficial veins in the first month postpartum is significantly increased [15]. The use of estrogen-progestin contraceptives and estrogen therapy also increases the risk for thrombophlebitis, SVT, and venous thromboembolism. (See "Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis" and "Combined estrogen-progestin contraception: Side effects and health concerns".)

Prior vein thrombosis – Although phlebitis and thrombosis of the lower extremity superficial veins is more likely to occur in varicose veins, nonvaricose veins are affected in 5 to 10 percent of patients [13]. In the absence of varicose veins, thrombosis of the lower extremity superficial veins may be a marker for a hypercoagulable state or malignancy, conditions for which the patient should be evaluated.

A history of prior DVT as well as current DVT increases the risk for SVT [11]. Conversely, a history of SVT increases the risk for future DVT. In a study using data from the multiple environmental and genetic assessment (MEGA) of risk factors for venous thrombosis study, patients with a remote history of SVT had an increased risk of developing DVT (odds ratio [OR] 6.3, 95% CI 5.0-8.0) and pulmonary embolism (OR 3.9, 95% CI 3.0-5.1), but thrombophilia was only weakly associated with superficial thrombophlebitis, implicating stasis from varicose veins and obesity as more important factors [16]. (See 'Concurrent thromboembolism' below and "Overview of the causes of venous thrombosis", section on 'Superficial vein thrombosis'.)

Malignancy and hypercoagulable states — Phlebitis and thrombosis of the lower extremity superficial veins is associated with malignancy, hypercoagulable states, and thromboangiitis obliterans (ie, Buerger disease). In one study, risk factors were identified in 62 percent of patients with superficial thrombophlebitis in nonvaricose veins, including thrombophilia (20 out of 42 patients), malignancy (2 out of 42 patients), and other nonmalignant systemic disease (4 out of 42 patients) [13].

Some inherited (eg, Factor V Leiden, prothrombin gene mutation) and acquired thrombophilic states are also associated with an increased risk of phlebitis and thrombosis of the lower extremity superficial veins [5]. (See 'Other evaluation' below.)

Buerger disease is a segmental inflammatory disease affecting the small and medium-sized arteries and veins in the distal extremities, often presenting in its early stages as superficial phlebitis. (See "Thromboangiitis obliterans (Buerger disease)", section on 'Clinical features'.)

Trousseau syndrome of recurrent migratory phlebitis is associated with adenocarcinomas, particularly pancreatic cancer. (See "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer".)

Intravenous catheter use – SVT can occur as a complication of lower extremity central venous catheterization [17]. SVT associated with catheter use is due to a combination of endothelial injury and venous stasis. The upper extremity veins are affected far more commonly than lower extremity veins due to the frequency with which the upper extremity is used for access compared with the lower extremity. (See "Catheter-related upper extremity venous thrombosis in adults".)

CLINICAL PRESENTATIONS — Most patients present clinically with typical findings associated with venous inflammation and thrombosis. Signs of inflammation (ie, phlebitis) are readily identified in tributary veins (often varicosities), which are directly under the skin. Inflammatory changes associated with superficial vein thrombosis often cannot be appreciated since the superficial axial veins are typically 1.5 cm or more beneath the skin, especially in more cephalad thigh region. Symptoms and signs of venous thromboembolism (VTE; ie, deep vein thrombosis [DVT], pulmonary embolism) can also occur. When pulmonary embolism occurs related to superficial vein thrombosis (SVT), it is more likely related to SVT located in the above-knee segment of the great saphenous vein [18]. (See 'Concurrent thromboembolism' below.)

Uncomplicated — Most clinical presentations are uncomplicated with typical findings of tenderness, induration, pain, and/or erythema along the course of a superficial vein, usually a tributary varicosity. The degree of inflammation (ie, phlebitis) varies depending on the length of the vein affected. In addition, there is often a palpable, sometimes nodular cord due to thrombus within the affected vein. Persistence of this cord when the extremity is raised suggests the presence of thrombus. Low-grade fever may be present in uncomplicated superficial thrombophlebitis, but high fever should increase suspicion for suppurative superficial thrombophlebitis. (See 'Suppurative thrombophlebitis' below.)

Complicated — Complicated presentations include those that involve infection of the vein, those associated with thromboembolism, and those that are recurrent.

Suppurative thrombophlebitis — High fever, fluctuance, and/or purulent drainage suggest infection within the vein (ie, suppurative or septic thrombophlebitis). Suppurative thrombophlebitis should be suspected when erythema extends significantly beyond the margin of the vein. Septic thrombophlebitis is uncommon in the absence of a history of venous cannulation (ie, venipuncture or catheterization). (See "Catheter-related septic thrombophlebitis".)

Concurrent thromboembolism — Signs and symptoms of VTE (DVT, pulmonary embolism) may accompany the typical clinical features of SVT as described above. The risk for VTE is the highest immediately following a diagnosis of SVT but persists over time. A study compared rates of VTE in patients with a first-time diagnosis of SVT with those of a comparison cohort [9]. The risk was significantly increased and highest in the first three months (hazard ratio [HR] 71.4, 95% CI 60.2-84.7) and decreasing but still significantly higher after five years (HR 5.1, 95% CI 4.6-5.5). (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

SVT and DVT can coexist either as contiguous extensions of thrombus via the saphenofemoral junction, saphenopopliteal junction or perforating veins, or as a noncontiguous finding (table 2) [1,7,11,19-22]. Synchronous thrombus remote from the location of the superficial vein thrombosis, and even thrombosis in the contralateral extremity, have been described. In addition to well-established risk factors for DVT (eg, prior DVT, thrombophilia), factors predicting a diagnosis of DVT when SVT is identified on physical examination include [22-28]:

Age >60 years

Male sex

Bilateral SVTs

Presence of systemic infection

Absence of varicose veins

A systematic review of 37 studies identified an incidence of coexistent DVT in patients with SVT that ranged from 6 to 53 percent [7]. The observed variability was due to the wide diversity of patients studied and methods used in the published reports; lower incidences are reported in primary care settings compared with vascular laboratory populations. The highest incidence of DVT was seen when the above-knee great saphenous vein was involved due to increased incidence of thrombus propagation [29-31]. (See 'When to obtain duplex ultrasound' below.)

Although much less common for superficial compared with deep vein thrombosis, clinical signs and symptoms of pulmonary embolism can also occur [7,18,19]. In the systematic review described above, the incidence of pulmonary embolus was reported in eight studies and ranged between 1 and 33 percent [7]. The higher incidence was from a study that reported the incidence of PE as identified on scintigraphy performed in all patients upon diagnosis of SVT. Concurrent symptomatic PE is diagnosed in approximately 5 percent of patients with SVT at the initial presentation. A later study of 844 patients with thrombosis of the lower extremity superficial veins affecting a segment ≥5 cm in length found symptomatic pulmonary embolus in 4 percent of patients [31]. In patients who did not present with pulmonary embolus, 0.5 percent of the patients developed symptomatic pulmonary embolus despite anticoagulant therapy.

Recurrent or migratory thrombophlebitis — Thrombosis of the lower extremity superficial veins can occur as an isolated event but can be recurrent in the same vein. In some patients, distinctly different vein segments can be affected over time. When this occurs without an identifiable cause, it is referred to as migratory thrombophlebitis. Migratory thrombophlebitis can be associated with an underlying malignancy, particularly carcinoma of the pancreas [32,33].

Skin hyperpigmentation may be seen overlying the course of previously affected veins and can occur after a single episode. It is due to breakdown of the thrombus and deposition of hemosiderin into the tissues.

DIAGNOSIS — The diagnosis of phlebitis and thrombosis of the lower extremity superficial veins is usually clinically apparent based upon the patient's complaints and physical examination as described above, especially in patients with known risk factors. The need for duplex ultrasound or further evaluation with laboratory or other studies depends upon the clinical scenario. Most feel that duplex examination is essential for patients with suspected superficial vein thrombosis (SVT; ie, thrombus within the axial veins) due to the high rate of concurrent deep vein thrombosis (DVT), as well as to accurately make the diagnosis and define that anatomic extent of the thrombus so the patient can be reevaluated should they demonstrate clinical signs of propagation. (See 'When to obtain duplex ultrasound' below and 'Other evaluation' below.)

When to obtain duplex ultrasound — While a decision to obtain a duplex ultrasound depends on whether the information obtained will likely change clinical management, for most patients we suggest ultrasound upon initial presentation to rule out the presence of coexistent DVT and to evaluate the location and extent of thrombosis (algorithm 1) [34-36]. The extent of thrombosis is often not appreciated by the clinician based on physical examination alone. Duplex ultrasound should also be performed for those in whom the clinical examination is uncertain, for lower extremity swelling that is greater than would be expected from thrombophlebitis alone, or for evidence of clinical progression during a period of follow-up.

Duplex ultrasound should routinely evaluate the deep and superficial axial veins to exclude DVT and superficial venous thrombosis as well as the location of the main perforator veins. It is important to evaluate the entire extent of the involved superficial vein, and the ultrasound technician should be asked to document the exact location and length of any identified thrombus. The need to treat superficial vein thrombosis is based upon the length of thrombus being greater than or equal to 5 cm long. Any isolated tributary superficial veins with thrombosis or thrombophlebitis should also be documented.

Duplex ultrasound can also help identify other pathology that may be a source of the patient's complaints (eg, popliteal cyst, muscle mass) [37,38]. (See 'Differential diagnosis' below.)

SVT can progress to involve the deep veins at any level in the lower extremity; however, the risk of DVT progressing from the great saphenous or an anterior accessory saphenous vein (at the saphenofemoral junction) or small saphenous vein (at the saphenopopliteal junction) is greater than with the perforating veins.

For patients with isolated uncomplicated phlebitis not affecting the axial veins and with no other risk factors for DVT, the likelihood of venous thromboembolism is low, and additional studies are generally not required. The patient should be treated symptomatically and undergo repeat clinical examination within 7 to 10 days to evaluate for resolution or progression. Resolution may take two to six weeks. Any worsening of clinical symptoms despite of treatment or clinical progression of signs of phlebitis on physical examination should prompt evaluation with duplex ultrasound. Clinical progression includes worsened pain, increased swelling, or extension of a region of erythema or palpable cord. (See 'Treatment of phlebitis' below.)

Some patients may complain of pain along the known course of a superficial vein (eg, inner medial thigh and calf) but have minimal physical findings (ie, no palpable cord or erythema) to support a clinical diagnosis of superficial thrombophlebitis or SVT. However, it is important to remember that in all patients and in particular patients with obesity, the superficial veins are situated several centimeters below the surface of normal-appearing skin (especially in the thigh region), and erythema may not be as visually apparent on physical examination. Although these patients likely have thrombosis of the superficial veins, they may have DVT [11,20-22]. Duplex imaging is indicated in such cases to establish the diagnosis and to exclude the presence of DVT. It is important to note that even in a thin or normal-sized individual, SVT in the more cephalad great saphenous vein may not have the classic overlying erythema due to the depth of the vein in this location.

Patients with clinical symptoms that are clearly along the course of an axial vein and indicative of SVT should undergo duplex examination to exclude extension into the deep venous system. Given their common risk factors, the association of superficial and deep venous thrombosis is not surprising. For patients with SVT in proximity (≤5 cm) to the deep vein system, there is a high prevalence of concomitant DVT. The risk of pulmonary embolism is also higher when SVT occurs in the more cephalad great saphenous vein. Coexisting DVT is diagnosed with ultrasound in approximately 25 percent of cases of SVT, with the highest risk occurring when the more cephalad great saphenous vein is involved [11,18,20-22,24,25,39-42]. The physical findings can lag the extent of thrombosis as detected by duplex scan. As an example, duplex scan may identify thrombus encroaching upon the saphenofemoral junction in a patient with an erythematous, hot, tender cord confined to the course of the saphenous vein below the knee and without symptoms in the thigh. (See 'Concurrent thromboembolism' above.)

Any patient with significant lower extremity swelling should undergo duplex evaluation to rule out DVT, iliac venous compression, or deep venous valvular insufficiency.

Duplex ultrasound is frequently performed within a week following endovenous ablation to exclude thrombus propagation into the deep system (thermal/nonthermal ablation), endovenous heat-induced thrombus (EHIT), or propagation of glue or thrombus with cyanoacrylate adhesive ablation, which complicates this procedure in 1 to 3 percent of patients [43,44]. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Postoperative duplex ultrasound' and "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease", section on 'Postoperative duplex ultrasound'.)

When symptoms and signs of phlebitis occur in a lower extremity with a central catheter (ie, groin), duplex ultrasound should be performed to evaluate for DVT, particularly if pain and erythema are closely associated with the catheter [17].

There are limited data evaluating the cost effectiveness of serial duplex examinations [45]. However, for patients who will not be anticoagulated, repeat or serial ultrasound can determine whether thrombus stabilization, extension, or interim development of DVT has occurred (algorithm 1) [46]. (See 'Dose and duration' below.)

Duplex findings — Findings on duplex include vein wall thickening and perivenous or subcutaneous edema. Luminal thrombus may or may not be present [24]. Direct extension of thrombus from the superficial to deep veins at confluences (eg, saphenofemoral junction, saphenopopliteal junction) or via perforating veins can occur, and these regions should be evaluated and documented in detail (length, distance from junction with deep veins) at initial duplex examination and at any follow-up examinations. When superficial and deep vein thrombosis exist as a contiguous finding on duplex ultrasound, it may be difficult to determine whether the superficial or deep venous system was affected first. SVT can represent a retrograde extension of thrombus from the deep veins to the superficial veins, which can occur in patients with venous valvular incompetence [11,20-22].

Findings of perivenous fluid collections or air in the tissues indicated the presence of infection. (See 'Suppurative thrombophlebitis' above.)

Other evaluation — The need for any other evaluation depends upon the clinical scenario. Most patients with uncomplicated phlebitis will not require further laboratory evaluation or workup. For patients who require anticoagulation, we obtain baseline coagulation parameters and a D-dimer at the initiation of treatment and again at 45 days. If the D-dimer remains elevated, it is an indication that the thrombus burden has not completely resolved, and continuation of anticoagulation may be warranted.

For patients with clinical signs consistent with suppurative phlebitis, we obtain a complete blood count and blood cultures.

Abnormal coagulation profiles have been identified in patients with thrombosis of the lower extremity superficial veins. However, as with DVT, screening patients for hypercoagulability following a solitary episode is low yield and not cost effective. While no consensus exists, screening for hypercoagulability should be considered in patients with SVT not associated with varicose veins or recurrent SVT, along with a careful history and physical examination to assess for symptoms and signs consistent with malignancy or other thrombophilic conditions. (See "Evaluating adult patients with established venous thromboembolism for acquired and inherited risk factors", section on 'Evaluation for occult malignancy'.)

DIFFERENTIAL DIAGNOSIS — Other entities such as cellulitis, insect bites, lymphangitis, erythema nodosum, cutaneous polyarteritis nodosa, sarcoid granuloma, tendinitis, and Kaposi sarcoma may be clinically confused with superficial vein thrombosis (SVT) [12]. The presence of SVT in the vicinity of the patient's symptoms confirmed on ultrasound distinguishes SVT from other disorders.

Patients who complain of pain behind the knee without the typical obvious phlebitis may have a popliteal (Baker) cyst as a source of their complaints [37,38]. (See "Popliteal (Baker's) cyst".)

MANAGEMENT — Management of phlebitis and thrombosis of the superficial veins in the lower extremity includes treatment aimed at relieving symptoms (pain control, reducing inflammation) for all patients and serial clinical assessment that often includes ultrasound. Treatment may also include initiation of anticoagulation (prophylactic or therapeutic) for superficial vein thrombosis (SVT) depending on the location and the extent of thrombus, incorporating patient preference and the cost and convenience of the available treatments, and the burdens of follow-up visits and imaging.

General approach — The clinical approach to the diagnosis and treatment of phlebitis and thrombosis of the superficial veins in the lower extremity is provided in the algorithm (algorithm 1).

Initial management of uncomplicated phlebitis is supportive and is primarily aimed at alleviating symptoms, decreasing inflammation, and preventing propagation of thrombus. Treatment consists of extremity elevation (ie, waist level), warm or cool compresses, nonsteroidal anti-inflammatory drugs (NSAIDs), and compression therapy as tolerated [47]. The patient should be encouraged to remain ambulatory if possible (see 'Treatment of phlebitis' below).

Concurrent deep vein thrombosis (DVT) needs to be excluded using duplex ultrasonography if thrombosis is noted to be in the distribution of the great saphenous vein, small saphenous vein, or anterior accessory saphenous vein on clinical examination (figure 2 and figure 1A-B).

Antibiotic treatment is not indicated unless there are signs of infection (eg, high fever, purulent drainage) [48]. (See 'Suppurative thrombophlebitis' above.)

Anticoagulation is suggested for patients with SVT at increased risk for venous thromboembolism (VTE). Whether prophylactic or therapeutic dosing is suggested depends on the location and extent of thrombosis, which determines the risk for VTE, and the patient's medical history. (See 'Treatment of SVT' below and 'Dose and duration' below.)

There is no role for anticoagulation, prophylactic or therapeutic, for patients with superficial phlebitis alone (ie, without evidence of thrombosis) or superficial thrombophlebitis (ie, thrombosis of a tributary vein). (See 'Treatment of phlebitis' below.)

Patients with indications for anticoagulation, but in whom it is contraindicated, may be candidates for ligation of the vein (eg, high ligation at the saphenofemoral junction) to prevent propagation. Rarely, others with varicose vein SVT may benefit from vein excision to relieve local symptoms if there is not an appropriate response to symptomatic care or for recurrence of phlebitis. (See 'Complicated disease' below.)

Patients who present with complicated disease may require additional evaluation and management strategies.

(See "Catheter-related septic thrombophlebitis", section on 'Management'.)

(See "Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)".)

(See "Cancer-associated hypercoagulable state: Causes and mechanisms".)

Treatment of phlebitis — Most symptoms related to inflammation of the vein (ie, superficial phlebitis, superficial thrombophlebitis) will respond within a few days to weeks with supportive measures. For patients with superimposed limited thrombus, resolution of pain usually occurs within a week; however, for involved superficial tributary veins (typically varicosities), a venous cord may remain palpable for several months [48]. It is important to distinguish between phlebitis and thrombus in a tributary varicose vein (superficial phlebitis, superficial thrombophlebitis) versus thrombus within an axial superficial vein (ie, superficial vein thrombosis) because treatment of the latter may also involve anticoagulation.

Pain management — NSAIDs are effective in relieving the pain associated with venous inflammation. NSAIDs are appropriate for the treatment of superficial phlebitis or superficial thrombophlebitis; however, due to concern over increased bleeding risk, we avoid NSAIDs in patients with superficial vein thrombosis who will be anticoagulated. (See 'Intermediate risk for VTE: prophylactic anticoagulation' below.).

Other measures to help relieve pain include limb elevation and ice over the affected vein.

Compared with placebo, NSAIDs have reduced recurrence of phlebitis and thrombus extension [27,49-51]. In a randomized trial to significantly decrease extension and/or recurrence compared with placebo (30 versus 16 percent, respectively) [27]. However, no one NSAID has been found to be more effective than another in the treatment of phlebitis [2,49]. In trials, NSAIDs administered for a couple of weeks have been sufficient for relieving associated pain symptoms. Common oral NSAIDs used to relieve acute pain associated with venous inflammation include ibuprofen, diclofenac, and ketoprofen. (See "NSAIDs: Therapeutic use and variability of response in adults" and "Nonselective NSAIDs: Overview of adverse effects" and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)

Limited data suggest that topical agents may alleviate symptoms and hasten resolution of phlebitis of the superficial tributary veins [2,52]. The vein to be treated cannot be too deeply situated. Topical diclofenac gel appears to be as effective as oral diclofenac in alleviating pain but may be associated with hepatotoxicity [49,53-55]. Piroxicam gel was found to have no benefit compared with placebo [56]. In a randomized trial, topical heparin applied three times daily for up to seven days was found to be more effective than placebo [57,58]. However, another trial found no benefit for topical heparin [56]. Defibrotide is an agent that enhances endogenous fibrinolysis. In two small, randomized trials, defibrotide significantly decreased the inflammatory response of thrombosed veins [59,60].

Compression therapy — Class II or higher compression stockings (table 3) can be offered to patients with phlebitis and thrombosis of the superficial veins, if not contraindicated (eg, peripheral artery disease); however, some patients may find them painful to put on. In the Comparison of ARIXTRA (fondaparinux) in lower Limb Superficial Thrombophlebitis (CALISTO) trial, which compared fondaparinux with placebo (see 'Intermediate risk for VTE: prophylactic anticoagulation' below)), 83 percent of patients used compression stockings [61]. Although treatment with compression stockings alone is not as effective as treatment with compression stockings combined with NSAIDs or anticoagulation, compression stockings may provide an additional benefit [59,62]. A small trial randomly assigned 80 patients to compression stockings or no compression [63]. All patients were treated with low-molecular-weight heparin (LMWH). Relative to baseline, significant improvements in clinical symptoms and quality-of-life were similar for each group, but at day 7 the compression therapy group had ultrasound evidence of faster thrombus regression. Some patients may not tolerate compression stockings due to extensive inflammation, and under this circumstance there is no need to insist on using stockings, particularly if anticoagulation has also been initiated. When used, the length of compression stocking should encompass the entire extent of the affected vein, if possible. (See "Compression therapy for the treatment of chronic venous insufficiency", section on 'Static compression therapy'.)

Treatment of SVT — For patients with SVT, the measures described above may help relieve pain (see 'Treatment of phlebitis' above), but anticoagulation, when indicated, provides more lasting relief, prevents recurrence, and minimizes the future risk for thromboembolism. Whether to include anticoagulation as part of treatment and its dosing depends on the location and extent of the thrombus. Patients with SVT can be stratified as low, intermediate, or at elevated risk for developing VTE. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Baseline thrombosis risk'.)

For the patients with SVT who have indications for anticoagulation but who cannot be anticoagulated, we ligate the saphenous vein at the saphenofemoral junction or saphenopopliteal junction.

Low risk for VTE: no anticoagulation — Patients with isolated, uncomplicated SVT have a low risk for thromboembolism and do not initially need to be treated with anticoagulation [2,47,64,65]. This includes patients with:

SVT remote from the saphenofemoral junction or saphenopopliteal junction, such as SVT involving the below-knee, rather than the above-knee great saphenous vein

Focal SVT with axial vein involvement (ie, ≤5 cm in length)

and

No medical risk factors for VTE (see 'Risk factors' above)

Isolated, uncomplicated SVT does require close follow-up to watch for evidence of propagation of thrombus, which may occur over the course of several weeks. If there is no propagation, it may resolve with symptomatic care alone. We use NSAIDs as the preferred initial medication to control pain and decrease inflammation (algorithm 1). We also suggest routine serial examinations and repeat duplex ultrasound to identify patients who develop thrombus extension and who may then benefit from anticoagulation, as many of these patients do exhibit subsequent propagation. (See 'Treatment of phlebitis' above and 'When to obtain duplex ultrasound' above.)

Intermediate risk for VTE: prophylactic anticoagulation — Based predominantly on the outcomes of the CALISTO trial [61], we suggest prophylactic anticoagulation for patients with uncomplicated axial vein thrombosis (ie, SVT) at intermediate risk for thromboembolism (algorithm 1). This includes patients with:

SVT in proximity (3 to 5 cm) to the deep venous system, particularly if involving the great saphenous vein or small saphenous vein

SVT that is more extensive with the affected vein segment ≥5 cm, rather than focal involvement

SVT that propagates with symptomatic care

and

The patient has no medical risk factors for VTE (see 'Risk factors' above)

Effectiveness — Compared with placebo, unfractionated heparin, LMWH, and fondaparinux have all reduced thrombus extension and/or recurrence of phlebitis [27,50,51]. A significant reduction in the incidence of pulmonary embolism has not been consistently demonstrated for any of these agents [2,27,61,64,66]. Most trials that have evaluated LMWH as anticoagulation for SVT of the lower extremity are small, with methodologic weaknesses [27,51,62,67-70]. Early trials treating patients with LMWH improved understanding that therapeutic doses of LMWH do not offer an advantage over prophylactic doses and that treatment for 30 days is too short of a duration to provide a lasting result. [2,27,50,51,61,64,66].

The CALISTO trial, the largest of the available trials, randomly assigned 3002 patients to receive fondaparinux (2.5 mg subcutaneous daily for 45 days) or placebo [61]. Patients had duplex-confirmed SVT over at an least 5 cm segment of vein (ie, anatomic low risk). Patients with involvement of the great saphenous vein within 3 cm of the saphenofemoral junction were excluded, as were patients with medical risk factors for thromboembolism (eg, recent surgery, prior phlebitis or DVT, cancer). Interval duplex examination was performed at the discretion of the physician. Less than 5 percent of patients developed thrombus extension or DVT. This trial demonstrated a significant reduction in the primary efficacy outcome for the treatment group compared with placebo at 47 days immediately after stopping treatment (0.9 versus 5.9 percent) and out to day 77. The incidence of each component of the primary efficacy outcome was also significantly reduced in the fondaparinux group (symptomatic DVT [0.2 versus 1.2 percent], symptomatic PE [0 versus 0.3 percent], symptomatic SVT extension [0.3 versus 3.4 percent], symptomatic SVT recurrence [0.3 versus 1.6 percent]), except for the outcome of death (0.1 percent in both groups).

In a post hoc analysis, the outcomes of 109 patients with symptomatic thrombus extension among the 1500 patients in the placebo arm were evaluated [71]. The risk of subsequent VTE was similar for extension that occurred to ≤3 cm or >3 cm from the saphenofemoral junction (9.3 [5/54] versus 8.9 [5/56] percent, respectively). In those with extension ≤3 cm, DVT occurred in four patients and pulmonary embolism in one, and in those with extension >3 cm, DVT occurred in three patients and pulmonary embolism in two patients. A cost model derived from the CALISTO trial data and other studies found that treatment of acute, isolated SVT with fondaparinux for 45 days may not be cost effective in low-risk patients [72].

Extension of thrombus and recurrence despite anticoagulation has been reported [73].

Dose and duration — While selected patients with SVT may benefit from prophylactic anticoagulation [74], the optimal agent, dose, and duration remain debated [2,47,75-77]. Depending upon physician and patient preference, we suggest subcutaneous prophylactic-dose fondaparinux 2.5 mg daily, an intermediate subcutaneous dose of LMWH (eg, dalteparin 5000 units every 12 hours, enoxaparin 40 mg daily), or oral prophylactic-dose rivaroxaban (10 mg daily), for a duration of 45 days. Briefer periods of anticoagulation appear to be too short to prevent recurrence in the long run [27]. A high rate of recurrent superficial phlebitis has been reported following early discontinuation of anticoagulation. (See 'Other evaluation' above.)

In addition to fondaparinux (discussed above with the CALISTO trial), unfractionated heparin, a variety of LMWHs in various dosing regimens, and oral rivaroxaban have been evaluated [2,27,66,67,78,79].

Early studies found no significant differences in efficacy for short-term treatment [27,67,80,81], fixed-dose or weight-adjusted nadroparin [67,68], high-dose versus low-dose enoxaparin [27], or dalteparin, which was introduced later [78,82]. Better outcomes were found for intermediate compared with prophylactic dosing of LMWH for 30 days and intermediate dosing for 30 days compared with 10 days [66]. Higher-dose unfractionated heparin (10,000 to 12,500 units twice daily) compared with the lower doses (5000 units twice daily) had a significantly lower incidence of saphenous thrombus extension (3.3 versus 20.0 percent) [69,83]. The reported incidence of bleeding complications with LMWH or subcutaneous heparin has been low, likely due to the fact that patients with an increased risk for bleeding (eg, previous peptic ulcer, poorly controlled hypertension, renal insufficiency) have generally been excluded from study [61,62].

Direct factor Xa inhibitors have been used for the prevention and treatment of DVT [79,84] and may offer a less burdensome and less expensive oral treatment option for SVT as well. The SURPRISE trial (prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: the open-label, randomized, noninferiority phase 3b trial), randomly assigned 472 patients with SVT at high risk for VTE to oral rivaroxaban (10 mg each day) or subcutaneous fondaparinux (2.5 mg daily) for 45 days [84,85]. This trial was designed to evaluate patients with SVT and at least one risk factor. No significant differences were found for the primary efficacy outcome at 45 or 90 days (composite of symptomatic DVT or pulmonary embolism, progression or recurrence of SVT, and all-cause mortality; hazard ratio [HR] 1.9, 95% CI 0.6-6.4), or for the individual endpoints. There were no major bleeds in either group, but more clinically relevant nonmajor bleeding occurred in the rivaroxaban group (3 versus <1 percent). This trial demonstrated noninferiority of rivaroxaban when compared with fondaparinux at prophylactic doses for the prevention of subsequent thromboembolic risk over a period of 90 days from the initial diagnosis of SVT. Thus, rivaroxaban may offer a more cost-effective, oral option for the treatment of patients with SVT. (See "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects".)

Elevated risk for VTE: therapeutic anticoagulation — For patients with an elevated risk for VTE, we provide therapeutic anticoagulation at a dose and duration as with treatment for DVT. (See "Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)", section on 'Patients at low risk of bleeding'.)

Patients at elevated risk include:

SVT identified initially or that subsequently propagates within 3 cm of the deep venous system, particularly if involving the great saphenous vein or small saphenous vein

SVT that propagates despite prophylactic anticoagulation

Recurrent SVT after cessation of anticoagulation

or

SVT in a patient with medical risk factors for VTE (eg, prior DVT, thrombophilia) (see "Overview of the causes of venous thrombosis")

Whether SVT within a perforator vein is regarded as intermediate or elevated risk for DVT is not defined.

In the SURPRISE trial described in detail above (see 'Dose and duration' above), when compared with the low-risk CALISTO trial, the rate of subsequent thrombotic events in the high-risk patients was much higher at 90 days. High risk was defined as age >65, male sex, previous thromboembolism or prior SVT, cancer, autoimmune disease, or involvement of nonvaricose veins. Approximately 50 percent of patients had a history of DVT, PE, or SVT. Many believe that high-risk SVT patients may warrant longer treatment based upon the results of this trial, although there are no studies specifically looking at this. It may be that they require longer treatment at prophylactic doses or that they require therapeutic anticoagulation, but this remains unknown. What we do know from this study is that high-risk patients with SVT from SURPRISE are very different from low-risk patients from CALISTO.

Treatment of specific veins — A summary of the approach to managing specific veins is reviewed in the sections below based on vein location. General principles, effectiveness, and specific treatment details are provided above. (See 'Treatment of phlebitis' above and 'Treatment of SVT' above.)

Great saphenous vein — For thrombus located in the great saphenous vein above the knee, in addition to symptomatic care (compression, elevation, ice, but no NSAIDs) (see 'Treatment of phlebitis' above), we provide prophylactic anticoagulation for a duration of 45 days if the thrombus is ≥5 cm long; however, if thrombus is within 3 cm of the saphenofemoral junction, we provide full-dose therapeutic anticoagulation for three months.

For thrombus in the great saphenous vein below the knee, we provide symptomatic care and monitor for propagation (clinically, ultrasound). In the author's experience, these often propagate and may be considered for prophylactic anticoagulation. For focal thrombus, clinical monitoring may be sufficient; however, serial duplex ultrasound more accurately monitors the extent and propagation of thrombus. If thrombus propagation is demonstrated, we provide prophylactic anticoagulation for a duration for 45 days.

Small saphenous vein — For thrombus located in the small saphenous vein, in addition to symptomatic care, we provide prophylactic anticoagulation for a duration of 45 days if the thrombus is ≥5 cm long; however, if thrombus is within 3 cm of the saphenopopliteal junction, we provide full-dose therapeutic anticoagulation for three months. While SVT in the small saphenous vein is less studied, we can extrapolate that thrombus in proximity to the saphenopopliteal junction should be treated the same as thrombus close to the saphenofemoral junction.

For focal thrombus, clinical monitoring may be sufficient; however, serial duplex ultrasound more accurately monitors the extent and propagation of thrombus. If thrombus propagation is demonstrated, we provide prophylactic anticoagulation for a duration for 45 days.

Perforating veins — For thrombus located in a perforating vein, in addition to symptomatic care, anticoagulation is individualized. Thrombosis occurring in perforator veins is less well studied, but we can extrapolate that thrombus in proximity to the deep veins via a perforator is like thrombus close to the saphenofemoral junction, and anticoagulation, prophylactic or therapeutic, may be warranted depending on the perceived risk for VTE.

Tributary veins — For thrombus in a tributary vein (typically a varicosity), we monitor for propagation using ultrasound. If thrombus propagation occurs, we provide prophylactic anticoagulation for a duration of 45 days.

Complicated disease — In addition to symptomatic care, patients with complicated presentations as described below require anticoagulation or additional treatments or surgery. (See 'Treatment of phlebitis' above and 'Complicated' above.)

Suppurative thrombophlebitis — For any patient suspected to have suppurative thrombophlebitis, systemic antimicrobial therapy targeted to the most likely organisms and tailored to the culture and sensitivity of cultures are indicated. (See "Catheter-related septic thrombophlebitis", section on 'Management'.)

Surgical drainage and potentially vein excision may be needed to remove the septic focus if there is not an appropriate response to antibiotics [86].

Venous thromboembolism — Patients with SVT who have concomitant VTE are managed in accordance to established guidelines, in addition to symptomatic care [47]. (See "Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)" and "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults".)

Recurrent thrombophlebitis — Recurrent thrombophlebitis in a vein that previously responded to conservative therapy may require vein excision to prevent re-recurrence. For some patients with recurrent thrombophlebitis, vein excision can be performed once acute inflammation has subsided; removal of the vein precludes another episode of phlebitis at that location [62,64,87]. Two episodes in the same vein should prompt a discussion for intervention. However, compared with anticoagulation, surgical therapy (ligation of the saphenofemoral junction or excision of thrombosed superficial veins) appears to be associated with higher rates of VTE in the acute period [62,64,88]. Additional evaluation for hypercoagulability or cancer may be warranted for patients with recurrent thrombophlebitis, particularly in the absence of varicose veins. (See 'Other evaluation' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Superficial vein thrombosis, deep vein thrombosis, and pulmonary embolism".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Superficial vein phlebitis and thrombosis (The Basics)")

SUMMARY AND RECOMMENDATIONS

Lower extremity phlebitis and superficial vein thrombosis – Phlebitis and superficial vein thrombosis is generally benign and self-limited. When the axial veins (ie, great saphenous, anterior accessory saphenous, or small saphenous veins) are involved (typically varicosities), we refer to this as superficial vein thrombosis (SVT), which can be associated with concurrent deep vein thrombosis (DVT) or pulmonary embolism (PE) at the initial presentation. Following appropriate management, there is also a subsequent risk of symptomatic DVT, symptomatic PE, extension of thrombus, and recurrence of the SVT. (See 'Introduction' above.)

Risk factors – The risk of phlebitis and superficial vein thrombosis is increased in patients with varicose veins, abnormal coagulation or fibrinolysis, endothelial dysfunction, malignancy, infection, venous stasis, intravenous therapy, or intravenous drug abuse. Vein thrombosis in the absence of venous insufficiency should prompt a workup for occult malignancy and hypercoagulability. (See 'Risk factors' above.)

Clinical presentations – The clinical diagnosis of SVT relies on findings of pain, tenderness, induration, and/or erythema along the known course of a superficial, typically varicose, vein. It is important to remember that the superficial veins can be several centimeters below the surface of normal-appearing skin, particularly in those with obesity, and patients may complain of pain (eg, along inner medial thigh) but have minimal physical findings (ie, no erythema or palpable cord). (See 'Clinical presentations' above.)

Diagnosis – For patients with suspected thrombosis of an axial vein (great saphenous, anterior accessory saphenous, small saphenous veins), we suggest ultrasound upon initial presentation to rule out the presence of coexistent DVT and to evaluate the location and extent of thrombosis. Duplex ultrasound should also be performed for those in whom the clinical examination is uncertain, for lower extremity swelling that is greater than would be expected from thrombophlebitis alone, or for evidence of clinical progression during a period of follow-up. (See 'When to obtain duplex ultrasound' above.)

Management

Treatment of phlebitis – For all patients with phlebitis, symptomatic care measures should be instituted and consist of extremity elevation, warm or cool compresses, compression stockings, and pain management. (See 'Treatment of phlebitis' above.)

Monitoring – Patients should undergo repeat physical examination within 7 to 10 days of their initial diagnosis to evaluate for resolution or progression. Any worsening of clinical symptoms or extension of signs of phlebitis on physical examination should prompt duplex ultrasound. (See 'When to obtain duplex ultrasound' above.)

Anticoagulation – A decision for anticoagulation is based on the patient's risk for venous thromboembolism (VTE), which can be stratified as low, intermediate, or elevated. Management of specific veins is reviewed in detail above. (See 'Treatment of SVT' above and 'Treatment of specific veins' above.)

-Low risk for VTE – For patients at low risk for VTE, we suggest supportive care as first-line therapy, rather than anticoagulation (Grade 2C). Low risk patients include those with SVT remote from the saphenofemoral junction or saphenopopliteal junction (eg, below knee great saphenous vein), focal SVT with axial vein involvement (ie, ≤5 cm in length), and the patient has no medical risk factors for VTE.

-Intermediate risk for VTE – For patients at intermediate risk for VTE, we suggest prophylactic anticoagulation for 45 days rather than supportive care alone (Grade 2C). Intermediate risk patients include those with SVT in proximity (3 to 5 cm) to the deep venous system, particularly if involving the great or small saphenous vein; SVT that is more extensive with the affected vein segment ≥5 cm; SVT that propagates with symptomatic care; and the patient has no medical risk factors for VTE. For prophylaxis, fondaparinux, low-molecular-weight heparin, unfractionated heparin, direct oral anticoagulants, and vitamin K antagonists appear to be equally effective. (See 'Dose and duration' above.)

-Elevated risk for VTE – For patients at elevated risk for VTE, we suggest therapeutic anticoagulation, rather than prophylactic anticoagulation with a dose and duration like that selected for DVT (Grade 2C). Elevated-risk patients include SVT identified initially or that subsequently propagates within 3 cm of the deep venous system, particularly if involving the great saphenous vein or small saphenous vein; SVT that propagates despite prophylactic anticoagulation; recurrent SVT after cessation of anticoagulation; or SVT in a patient with medical risk factors for VTE (eg, prior DVT, thrombophilia). (See "Overview of the treatment of proximal and distal lower extremity deep vein thrombosis (DVT)", section on 'Patients at low risk of bleeding'.)

Complicated disease – In addition to symptomatic care, patients with complicated presentations (suppurative thrombophlebitis, concurrent thromboembolism, recurrent or migratory thrombophlebitis) may require additional treatments or surgery. (See 'Treatment of phlebitis' above and 'Complicated' above and 'Complicated disease' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Leonor Fernandez, MD, who contributed to an earlier version of this topic review.

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