Description

• Superficial thrombophlebitis refers to a thrombosis-related inflammatory process of superficial veins.
• Most common in the lower extremities with 60–80% of total cases involving the greater saphenous vein but can occur in any location
• Classically, it was considered a benign and self-limiting process, but recent evidence associates it with increased risk of thromboembolic complications including progression to venous thromboembolism (VTE), subsequent VTE, or recurrent superficial thrombophlebitis.
• Traumatic thrombophlebitis types:
  • Injury
  • IV catheter related
  • Intentional/iatrogenic (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, malignancy)
• 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

• Mean age is 60 years old.
• 50–70% in women
• More common in those with varicose veins
• Epidemiology by thrombophlebitis types:
  • Traumatic/IV related has no predominant age/sex.
  • Suppurative and more common in extremes of ages (neonates, elderly)
  • 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

Incidence

• Overall incidence is not well established. Current estimates put the incidence around 1.31 per 1,000 person-years, with increasing age associated with higher rates.
• Current incidence of catheter-associated septic thrombophlebitis is 0.5 per 1,000 days of peripherally inserted catheters.
• In pregnancy, incidence varies by trimester and postpartum. Per 1,000 person-years, incidence rates were 0.1, 0.2, 0.5, and 1.6 during the 1st, 2nd, and 3rd trimesters, and postpartum, respectively.
• Aseptic primary hypercoagulable state: Antithrombin III and heparin cofactor II deficiency incidence is 50/100,000 persons.
• Superficial migratory thrombophlebitis in 27% of patients with thromboangiitis obliterans

Prevalence

• Superficial thrombophlebitis is common with prevalence estimated between 3% and 11% of the general population.
• 1/3 of patients in a medical ICU develop thrombophlebitis that eventually progresses to the deep veins.

Etiology and Pathophysiology

• The process for thrombosis and phlebitis in superficial thrombophlebitis is variable but follows similar processes underlying thrombus formation in other vessels. These include venous stasis, vascular wall injury, microthrombi with subsequent platelet aggregation, and hypercoagulable states.
• Varicose veins play a primary role in etiology of lower extremity thrombophlebitis.
• Mondor disease pathophysiology not completely understood but thought to be related to local trauma/direct injury
• 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 or Buerger disease

Genetics
Not applicable other than hypercoagulable states

Risk Factors

• Varicose veins
• Immobilization
• Obesity
• Advanced age
• Postoperative states
• Pregnancy or postpartum
• Hypercoagulable status
• Estrogen-based oral contraceptives
• History of previous superficial thromboembolism or venous thromboembolic event
• Trauma (IV placement/IV drug use, burns, surgery)
• Tobacco use (thromboangiitis obliterans)

General Prevention

• Avoid catheterization when possible, especially in the lower extremity.
• Insert catheters under aseptic conditions, secure cannulas, and replace every 3 days.
• Early mobilization and use usual deep vein thrombosis (DVT) prophylaxis in high-risk patients (i.e., ICU, immobilized)
• Minimize risk factors as able.

Commonly Associated Conditions

• Increasing evidence of association between superficial thrombophlebitis and VTE
• Estimated lifetime risk of VTE is 4 to 6 times higher in those with history of superficial thrombophlebitis.
• 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.