Diagnostic criteria

Palermo 2009 SUPERFICIAL THROMBOPHLEBITIS Diagnostic criteria P.L. Antignani - C. Allegra Dept. of Angiology, S. Giovanni Hospital, Rome, Italy

“Superficial thrombophlebitis is a common and benign disease”. “When large population of patients with superficial venous thrombosis are studied, the association with deep vein thrombosis appears rather small. Thus systematic screening for deep vein thrombosis may not be warratened in the presence of superficial venous thrombosis unless additional risk factors are present (es. immobilitation) ”. Bounameaux H, Reber-Wesem MA: Arch Int Med 1997;157:1822-24 Today is different !

Superficial Venous Thrombosis (SVT) on healthy veins • Superficial venous thrombosis on varicose veins

Factors causing superficial venous thrombosis A blow, fracture, or other injury to the leg or directly on the vein. Prolonged bed rest, especially after surgery (which causes the blood to "pool" in the legs). Prolonged inactivity such as sitting in one position for extended periods of time (as on long car, train, or plane trips). Pregnancy Obesity Cancer Systemic autoimmune disorders (Behçet) Buerger’s disease Congenital thrombophilic conditions Varicose veins

Physical examination In each type of superficial thrombophlebitis, the condition presents as redness and tenderness along the course of the vein, usually accompanied by swelling. Bleeding also can occur at the site of a varicose vein. Although unusual, it may occur in the small saphenous vein, which empties into the popliteal vein. Superficial thrombophlebitis of the upper extremities usually occurs at infusion sites or sites of trauma. Superficial thrombophlebitis can occur in the external jugular vein if it has been used for an infusion site.

Superficial venous thrombosis Healthy vein Abundant intima proliferation and media fibrosis with non-important thrombosis are the hallmark of this form which may be associated with a systemic disease. Varicose vein It is characterized by a large thrombus in a varicose vein and a modest inflammatory process localized in the vessel surrounding but not in its wall.

Traumatic and iatrogenic phlebitis Superficial venous thrombosis following an injury usually occurs in an extremity, manifesting as a tender cord along the course of a vein juxtaposing the area of trauma. Ecchymosis may be present early in the disease, indicating extravasation of blood associated with injury to the vein, and this may turn to brownish pigmentation over the vein as the inflammation resolves. Thrombophlebitis frequently occurs at the site of an intravenous infusion and is the result of irritating drugs, hypertonic solutions, or the intraluminal catheter or cannula itself. This is by far the most common type of thrombophlebitis encountered. Usually, redness and pain signal its presence while the infusion is being given, but thrombosis may manifest as a small lump days or weeks after the infusion apparatus has been removed. It may take months to completely resolve. The features of the iatrogenic form of traumatic (chemical) phlebitis may be deliberately produced by sclerotherapy.

Phlebitis as the result of an infection In 1932, DeTakats suggested that dormant infection in varicose veins was a factor in the development of thrombophlebitis occurring at operation or after injection treatments, trauma, or exposure to radiation therapy. Altemeier and colleagues suggested that the presence of L-forms and other atypical bacterial forms in the blood may play an important etiologic role in the disease and recommended administration of tetracycline. Septic phlebitis usually occurs in association with the long-term use of an intravenous cannula inserted for the administration of fluid or medications. Suppurative thrombophlebitis is a more serious, even lethal, complication of intravenous cannulation and therapy and is characterized by purulence within the vein. It frequently is associated with septicemia. Aerobic and anaerobic as well as mixed infections have been related to superficial venous thrombosis. Aerobic organisms include Staphylococcusaureus, Pseudomonas, and Klebsiella; anaerobic bacteria include Peptostreptococcus, Propionibacterium, Bacteroides fragilis, and more recently, fungi.

Jadioux first described migratory thrombophlebitis in 1845 as an entity characterized by repeated thromboses developing in superficial veins at varying sites but most commonly in the lower extremity. Although numerous etiologic factors have been proposed, none has been confirmed. The association of carcinoma was first reported by Trousseau in 1856. Sproul noted migratory thrombophlebitis to be especially prevalent with carcinoma of the tail of the pancreas (50 %). Phlebitis occurs in diseases associated with vasculitis, such as polyarteritis nodosa (periarteritis nodosa) and Buerger disease. Buerger noted phlebitis in 8 of 19 patients, and Shionoya reported it in 43% of the 255 patients he followed. Migratory phlebitis

Mondor’s Disease Thrombophlebitis of the superficial veins of the breast and the anterior chest wall Mondor disease is a rare condition. The thrombophlebitis is usually located in the anterolateral aspect of the upper portion of the breast or in the region extending from the lower portion of the breast across the submammary fold toward the costal margin and the epigastrium. A characteristic finding is a tender cordlike structure that may be demonstrated best by tensing the skin by elevating the arm. The cause is unknown, but a search for malignancy is indicated. Mondor disease occurs after recurrent local trauma, breast surgery, with the use of oral contraceptives, and with a protein C deficiency.

Thrombosis in a varicose vein Superficial venous thrombosis frequently occurs in varicose veins. It may extend up and down the saphenous vein or may remain confined to a cluster of tributary varicosities away from the main saphenous vein. Superficial thrombosis along the course of the greater saphenous vein is observed more often to progress to the deep system. Although it may follow trauma to a varix, it often appears to occur without antecedent cause. Thrombosis develops as a tender hard knot in a previously noted varicose vein and is frequently surrounded by erythema. At times, bleeding may occur as the reaction extends through the vein wall. It frequently is observed in varicose veins surrounding venous stasis ulcers.

Main rule In the absence of varicose veins one should look for other reasons such as: - Malignancy elsewhere in the body, - Autoimmune diseases, - Buerger's disease, - An inherited tendency to clot

Differential Diagnoses Cellulitis Lymphangitis Neuritis Ruptured medial head of the gastrocnemius Tendonitis

Diagnostic criteria Patients who present with spontaneous superficial thrombosis without a previous indwelling intravenous catheter or other precipitating cause should be considered for evaluation for a hypercoagulable state. All patients with a past history of another thromboembolic event should undergo a workup. Evaluation should include tests for factor V Leiden and prothrombin gene mutations, protein C and protein S, antithrombin C, factor VIII, antiphospholipid antibodies, lupus anticoagulant and homocysteine.

Diagnostic criteria Schonauer et al reported a high factor VIII concentration to be an independent risk factor for recurrent superficial thrombosis after another episode of venous thromboembolism. De Godoy and Braile reported that 5.5% of patients with repetitive superficial venous thrombosis were positive for protein S deficiency. Other authors have reported that both factor V Leiden and the prothrombin gene mutation significantly increases the risk of superficial venous thrombosis.

Superficial venous thrombosis and hypercoagulable states L. Leon. Eur. J. Vasc.En. Surg. Jan 2005

Diagnostic criteria Migratory thrombophlebitis, especially without good cause, may be an indication for a more detailed evaluation of the patient in search of a malignant lesion. This also should include selective application of CT scans, mammography, colonscopy, serum carcinoembryonic antigen (CEA) and prostate-specific antigen (PSA).

Prevalence and investigation Data for prevalence vary greatly: 6-53% for coexistence, 2.6-15% for propagation, 0-33% for (asymptomatic) PE Superficial venous thrombosis is diagnosed in a clinical setting but ultrasonography is useful to define the thrombosis and check for concomitant DVT.

Imaging evaluation: ultrasound Duplex ultrasound evaluation is the diagnostic method of choice to search for venous thrombosis. Thrombosed veins may appear thickened or inflamed on ultrasound, but the most diagnostic finding is a lack of compressibility of the vein using the scan head. An experienced ultrasound technologist should be able to diagnose superficial venous thrombosis with a high sensitivity and specificity.

Aims of a non invasive evaluation Show the existence of superficial venous thrombosis Differentiate the acute phase from the residual thrombus Define the characteristic of thrombus Define if the vein is varicose or healthy

Imaging evaluation: ultrasound • Study of the deep veins (coexistence of a DVT) • Evaluation of the wall and of the lumen (differential diagnostic • between SVT on healthy vein and varicose one) • Collateralsinvolved • Extension of thrombosis and involvement of saphenous vein at upper • and lower knee and evaluation of not involved veins • Study of the perforanting veins and their possible involvement • Study of SF junctions and SP junctions with thrombosis extension • evaluation • Thrombus characteristic • Characteristic of the lumen if signs of past SVT are already present • Signs of recanalization

Most important findings • Verify if the clot is adherent to wall or not • Evaluate his extension to deep venous system We have to consider the SVT as DVT if the thrombus is localized into 2 cm from SFJ or SPJ

Imaging evaluation: ultrasound A key question concerns the location and extent of superficial thrombosis, as well as the proximity to the deep venous system at the saphenofemoral or saphenopopliteal junction. Lutter and associates reported that 12% of 186 patients with superficial thrombophlebitis of the great saphenous vein above the knee had extension into the deep venous system. In our case report the percentage is of 31,2 %. It is manadtory to evaluate the presence of an associated deep vein thrombosis in the ipsilateral as well as contralateral limb. After an initial diagnosis of superficial venous thrombosis, especially in the thigh region, a follow-up duplex ultrasound examination should be performed to look for progression of disease after treatment is initiated. A finding of no clot extension indicates successful therapy; thrombus extension or encroachment toward the deep venous system should prompt more aggressive treatment.

Venography Venography is rarely required to diagnose a superficial venous thrombosis. It should generally be avoided because of the potential complications of intravenous contrast administration, which can itself lead to phlebitis. Venography is not necessary to exclude the diagnosis of deep vein thrombosis, which can be excluded with duplex scanning. If information on the pelvic veins or iliac venous outflow tract is required, CT venography is usually preferable, if available.

Complications Extension into the deep venous system Complications of suppurative phlebitis include the following: Metastatic abscess formation Septicemia Hyperpigmentation over the affected vein Persistent firm nodule in subcutaneous tissues at site of affected vein

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Diagnostic criteria