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Superficial Venous Thrombophlebitis

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Authors

Brandan Mayer-Blackwell, MD
Family and Sports Medicine Physician
Kaiser Permanente

Daniel Vryhof, MD
Assistant Professor of Emergency Medicine
Columbia University Medical Center
New York City

Summary

  • Superficial Venous Thrombophlebitis (SVT) consists of a venous thrombus and associated inflammation in a superficial vein. Symptoms often include swelling, pain, and redness at the site of the vein.
  • Ultrasound of SVT should include specific documentation of the symptomatic area and the saphenofemoral junction.
  • On US, SVT is characterized by a noncompressible and often distended vein. The vein may also demonstrate a flow or filling abnormality on color power doppler.
  • There is a growing body of evidence that SVTs carry a meaningful risk for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
    • SVTs greater than 5cm in length or within 3cm of the saphenofemoral junction risk extension and embolization.
    • SVTs are frequently comorbid with DVT and PE. If a SVT is found, the provider should consider screening for DVT and in the right clinical setting, PE.
SVT is most frequently diagnosed in the lower extremities. Therefore, this chapter will focus on SVT diagnosis in the lower extremities, although many of the principles will apply to SVT investigation elsewhere in the body. There is variability in the procedural protocol for the SVT ultrasound exam and the extent of the venous system that is evaluated. Additionally, all or a portion of the SVT exam may be included when evaluating for a DVT. At a minimum, all SVT protocols should include specific ultrasound documentation of the symptomatic area(s) and the saphenofemoral junction. The saphenofemoral junction must be evaluated for extension of the clot into the deep venous system. A high frequency linear array probe is typically used. The patient is placed in frog leg position while supine, and the ultrasound provider scans from the medial aspect of the leg. As the majority of SVT occurs in the great and small saphenous veins, the ultrasound exam may start with an evaluation of these veins.
Anatomy of the veins of the leg (click to enlarge).
Clinical example of superficial thrombphlebitis
Clinical example of superficial thrombophlebitis.[1]Nicholls SC. Sequelae of untreated venous insufficiency. ” Seminars in interventional radiology. Copyright© 2005 by Thieme Medical Publishers, Inc , 333 Seventh Avenue. 2005;22(03).

Introduction

  • Superficial venous thrombophlebitis (SVT) consists of a venous thrombus in conjunction with inflammation of the affected superficial vein. Superficial venous thrombophlebitis is often used synonymously with superficial venous thrombosis.
  • Although distinctly separate clinical entities, deep vein thrombosis (DVT) and SVT share many of the same risk factors, such as vessel wall trauma, a hypercoagulable state, and venous stasis. The largest single risk factor for SVT is varicose veins [2]Decousus H, Quéré I, Presles E, et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study: A large, prospective epidemiologic study. Ann Intern Med. … Continue reading.
  • SVT occurs most often in the lower limbs, particularly the saphenous veins. The great saphenous veins account for approximately 63% of cases and the small saphenous veins approximately 14% [3]Czysz A, Higbee SL. Superficial Thrombophlebitis. In: StatPearls. StatPearls Publishing; 2021.. SVT can also occur in the arms, breast, penis, and other superficial veins. When it occurs in the breast it is termed Mondor’s Disease of the Breast.
  • SVT is usually diagnosed based on a clinical history of pain, swelling, and/or redness along the course of a superficial vein. The thrombosed vein can often be palpated as a firm cord.
  • D-dimer testing is less reliable for excluding SVT than it is for DVT [4]Czysz A, Higbee SL. Superficial Thrombophlebitis. In: StatPearls. StatPearls Publishing; 2021.[5]Binder B, Lackner HK, Salmhofer W, Kroemer S, Custovic J, Hofmann-Wellenhof. Association between superficial vein thrombosis and deep vein thrombosis of the lower extremity. Archives of Dermatology. … Continue reading.

Clinical Significance

  • SVT is not only clinically important because it is often symptomatic at the site of thrombosis, but it is also associated with DVT and pulmonary emboli.
    • The STEPH trial demonstrated that SVT existed concomitantly with DVT and PE in 24.6% (95% CI, 18.3%-31.7%) and 4.7% (95% CI, 2.04%-9.01%) of cases respectively[6]Frappé P, Buchmuller-Cordier A, Bertoletti L, et al. Annual diagnosis rate of superficial vein thrombosis of the lower limbs: the STEPH community-based study. J Thromb Haemost. 2014;12(6):831-838..
    • The OPTIMEV trial similarly found that SVT occurred with DVT and PE in 28.8% and 6.8% of cases respectively[7]Genty C, Sevestre M-A, Brisot D, et al. Predictive factors for concurrent deep-vein thrombosis and symptomatic venous thromboembolic recurrence in case of superficial venous thrombosis: The OPTIMEV … Continue reading.
  • High risk characteristics for SVT[8]Czysz A, Higbee SL. Superficial Thrombophlebitis. In: StatPearls. StatPearls Publishing; 2021.[9]Tait C, Baglin T, Watson H, et al. Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol. 2012;159(1):28-38.[10]Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College OF Chest Physician evidence-based clinical practice … Continue reading
    • Length greater than 5 cm
    • Location proximal to the knee
    • Location within 3 cm of the saphenofemoral junction
    • Comorbid active malignancy
  • A Cochrane review[11]Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Libr. Published online 2018. doi:10.1002/14651858.cd004982.pub6 in 2018 and the CALISTO[12]Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010;363(13):1222-1232. trial found that 45 days of treatment with Fondaparinux for isolated SVT reduced the risk of symptomatic venous thromboembolism (both pulmonary embolism and DVT), SVT extension, and SVT recurrence without a significant increase in major bleeding events.

Ultrasound Diagnosis

  • SVT is most frequently diagnosed in the lower extremities. Therefore, this chapter will focus on SVT diagnosis in the lower extremities, although many of the principles will apply to SVT investigation elsewhere in the body.
  • There is variability in the procedural protocol for the SVT ultrasound exam and the extent of the venous system that is evaluated. Additionally, all or a portion of the SVT exam may be included when evaluating for a DVT. 
clinical example of starting probe position
We suggest starting at the proximal Saphenofemoral Junction as a point of reference.
  • At a minimum, all SVT protocols should include specific ultrasound documentation of the symptomatic area(s) and the saphenofemoral junction. The saphenofemoral junction must be evaluated for extension of the clot into the deep venous system.

Commonly Used Scanning Technique

  • A high frequency linear array probe is typically used.
  • The patient is placed in frog leg position while supine, and the ultrasound provider scans from the medial aspect of the leg.
  • As the majority of SVT occurs in the great and small saphenous veins, the ultrasound exam may start with an evaluation of these veins.
  • One way to perform the ultrasound exam is to start with a transverse view of the femoral vein. From there, the great saphenous vein can be followed from the saphenofemoral junction inferiorly towards the ankle. It runs superficially in the subcutaneous tissue along the medial aspect of the thigh and calf.
Leg US saphenofemoral junction with and without compression 2
Ultrasound demonstrating saphenofemoral junction with and without compression
Leg US saphenofemoral junction normal and without compression
Normal ultrasound of the saphenofemoral junction without compression.
Leg US saphenofemoral junction normal and with compression
Normal ultrasound of the saphenofemoral junction with compression applied.
  • The small saphenous vein has varied anatomy but typically branches off the popliteal vein in the popliteal fossa or upper calf. It can be followed from the popliteal vein inferiorly to the ankle. The small saphenous vein is superficial, running along the subcutaneous tissue without a paired artery.
  • Color doppler and spectral pulse wave doppler can be used to determine venous flow:
    • A normal vessel should demonstrate spontaneous flow. Flow Increases with inspiration and decreases with expiration. This can be exacerbated by having the patient Valsalva, which will transiently decrease blood flow and may engorge the vein.
    • Color doppler in the longitudinal plane can be used as an adjunct for demonstrating patent segments and partially occlusive thrombi. On color doppler the lumen should fill in with color from wall to wall without a flow void. Spectral pulse wave doppler can help in assessing flow and valvular insufficiency.
Leg US saphenofemoral junction with and without compression
Ultrasound demonstrating saphenofemoral junction with and without compression
Leg US Example of color doppler
Example of color doppler

Characterizing SVT and related pathology

  • SVT is characterized by a filling defect and a non-compressible vein. By contrast, a normal vein should have uniform compressibility to light probe pressure, with complete apposition of the anterior and posterior wall. A clot will typically appear as anechoic or hypoechoic, and the associated vein is frequently distended. Over time, as a clot becomes chronic, it will increase in echogenicity and the vein will become less distended.
Leg US saphenofemoral junction clot present and without compression
Ultrasound showing saphenofemoral thrombosis without any compression.
Leg US saphenofemoral junction clot present and with compression
Ultrasound showing saphenofemoral thrombosis with compression. Note the inability to compress the veins.
  • Augmentation testing by compressing the vein distally can also increase venous flow and be used to help exclude a thrombosis. The usefulness of augmentation testing is decreased in paired veins as flow can circumvent a clot.
  • A clot greater than 5cm or within 3cm of the saphenofemoral junction should be noted as this can change anticoagulation management decisions [13]Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Libr. Published online 2018. doi:10.1002/14651858.cd004982.pub6[14]Scott G, Mahdi AJ, Alikhan R. Superficial vein thrombosis: a current approach to management. Br J Haematol. 2015;168(5):639-645.[15]Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis: American College OF Chest Physician evidence-based clinical practice … Continue reading.
  • If an SVT is found on ultrasound exam, a bilateral DVT study may be considered given the conditions occur concomitantly in approximately 25% of cases[16]Frappé P, Buchmuller-Cordier A, Bertoletti L, et al. Annual diagnosis rate of superficial vein thrombosis of the lower limbs: the STEPH community-based study. J Thromb Haemost. 2014;12(6):831-838.[17]Genty C, Sevestre M-A, Brisot D, et al. Predictive factors for concurrent deep-vein thrombosis and symptomatic venous thromboembolic recurrence in case of superficial venous thrombosis: The OPTIMEV … Continue reading.

Pearls and Pitfalls

  • SVT ultrasound protocols should include specific documentation of the symptomatic area(s) and the saphenofemoral junction.
  • The great saphenous vein can be found branching off the femoral vein while the small saphenous vein typically branches off the popliteal vein.
  • On ultrasound SVT is characterized by a filling defect and a non-compressible vein. Color doppler and spectral pulse wave doppler can help in assessing flow.
  • A clot greater than 5cm or within 3cm of the saphenofemoral junction is typically treated with fondaparinux anticoagulation for 45 days.
  • SVT frequently is comorbid with DVT and pulmonary emboli.

References

References[+]