Superficial Thrombophlebitis

Superficial Thrombophlebitis is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Superficial thrombophlebitis is venous inflammation with secondary thrombosis of a superficial vein.
  • Most common in the lower extremities (60–80%), but can occur in the upper extremities/neck
  • Generally a benign and self-limiting process, but can be painful
  • Traumatic thrombophlebitis types:
    • Injury
    • IV catheter related
    • Intentional (i.e., sclerotherapy)
  • Aseptic thrombophlebitis types:
    • Primary hypercoagulable states: disorders with measurable defects in the proteins of the coagulation and/or fibrinolytic systems
    • Secondary hypercoagulable states: clinical conditions with a risk of thrombosis (venous stasis, pregnancy)
  • Septic (suppurative) thrombophlebitis types:
    • Iatrogenic, long-term IV catheter use
    • Infectious, mainly syphilis and psittacosis
  • Mondor disease
    • Rare presentation of anterior chest/breast veins of women
  • System(s) affected: cardiovascular
  • Synonym(s): phlebitis; phlebothrombosis

Geriatric Considerations
Septic thrombophlebitis is more common; prognosis is poorer.

Pediatric Considerations
Subperiosteal abscesses of adjacent long bone may complicate the disorder.

Pregnancy Considerations
  • Associated with increased risk of aseptic superficial thrombophlebitis, especially during postpartum
  • NSAIDs are contraindicated during pregnancy.

Epidemiology

  • Predominant age
    • Traumatic/IV related has no predominant age/sex.
    • Aseptic primary hypercoagulable state
      • Childhood to young adult
  • Aseptic secondary hypercoagulable state
    • Mondor disease: women, ages 21 to 55 years
    • Thromboangiitis obliterans onset: ages 20 to 50 years
  • Predominant sex
    • Suppurative: male = female
    • Aseptic
      • Spontaneous formation: female (55–70%)
      • Mondor: female > male (2:1)

Incidence
  • Septic
    • Incidence of catheter-related thrombophlebitis is 88/100,000 persons per year.
    • Develops in 4–8% if cutdown is performed
  • Aseptic primary hypercoagulable state: Antithrombin III and heparin cofactor II deficiency incidence is 50/100,000 persons.
  • Aseptic secondary hypercoagulable state
    • In pregnancy, 49-fold increased incidence of phlebitis
    • Superficial migratory thrombophlebitis in 27% of patients with thromboangiitis obliterans
Prevalence
  • Superficial thrombophlebitis is common.
  • 1/3 of patients in a medical ICU develop thrombophlebitis that eventually progresses to the deep veins.

Etiology and Pathophysiology

  • Similar to deep venous thrombosis; Virchow triad of vessel trauma, stasis, and hypercoagulability (genetic, iatrogenic, or idiopathic)
  • Varicose veins play a primary role in etiology of lower extremity phlebitis.
  • Mondor disease pathophysiology not completely understood
  • Less commonly due to infection (i.e., septic)
    • Staphylococcus aureus, Pseudomonas, Klebsiella, Peptostreptococcus sp.
    • Candida sp.
  • Aseptic primary hypercoagulable state
    • Due to inherited disorders of hypercoagulability
  • Aseptic secondary hypercoagulable states
    • Malignancy (Trousseau syndrome: recurrent migratory thrombophlebitis): most commonly seen in metastatic mucin or adenocarcinomas of the GI tract (pancreas, stomach, colon, and gallbladder), lung, prostate, and ovary
    • Pregnancy
    • Estrogen-based oral contraceptives
    • Behçet, Buerger, or Mondor disease

Genetics
Not applicable other than hypercoagulable states

Risk Factors

  • Nonspecific
    • Varicose veins
    • Immobilization
    • Obesity
    • Advanced age
    • Postoperative states
  • Traumatic/septic
    • IV catheter (plastic > coated)
    • Lower extremity IV catheter
    • Cutdowns
    • Cancer, debilitating diseases
    • Burn patients
    • AIDS
    • IV drug use
  • Aseptic
    • Pregnancy
    • Estrogen-based oral contraceptives
    • Surgery, trauma, infection
    • Hypercoagulable state (i.e., factor V, protein C, or S deficiency, others)
  • Thromboangiitis obliterans: persistent smoking
  • Mondor disease
    • Breast cancer or breast surgery

General Prevention

  • Avoid lower extremity cannulations/IV.
  • Insert catheters under aseptic conditions, secure cannulas, and replace every 3 days.
  • Avoid stasis and use usual deep vein thrombosis (DVT) prophylaxis in high-risk patients (i.e., ICU, immobilized).

Commonly Associated Conditions

  • Frequently seen with concurrent DVT (6–53%)
  • Symptomatic pulmonary embolism can also be seen concurrently (0–10%).
  • Both DVT/PE can occur up to 3 months after onset of phlebitis.

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