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 groin, penis, or anterior chest/breast veins
• System(s) affected: cardiovascular
• Synonym(s): phlebitis; phlebothrombosis, superficial vein thrombosis (SVT)

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
• As NSAIDs are contraindicated during pregnancy, alternative therapeutic approaches are advised.

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
  • History of previous venous thromboembolic event (VTE)
• Traumatic/septic
  • IV catheter (plastic > coated)
  • Lower extremity IV catheter
  • Cutdowns
  • Burn patients
  • AIDS
  • IV drug use
• Aseptic
  • Pregnancy
  • Cancer, debilitating diseases
  • 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 or IVs.
• 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 superficial thrombophlebitis.