This patient was diagnosed with superficial phlebitis. When initially seen in the ED, there was clearly an area of tenderness and induration that ran in the distribution of the lesser saphenous vein. Palpation of the calf was tender as well, and a lower extremity ultrasound was done to rule out a deep venous thrombosis. The patient was discharged home with a prescription for compression stockings and an NSAID. She also was placed on an antistaphylococcal antibiotic because cellulitis could not be ruled out, and instructed to follow up with her primary care doctor in 48 hours.
Most of us have seen a case of superficial phlebitis or have family members with the condition. In general, it is fairly benign, but there are associations with deep venous thrombosis (DVT) and pulmonary embolism (PE) particularly when there is involvement of the proximal greater saphenous vein.
A discussion of this topic requires some terminology clarification. Superficial phlebitis is when a superficial vein of the upper or lower extremity demonstrates pain, tenderness, induration, or erythema. This may be due to an inflammatory reaction due to a catheter, drug infusion, infectious process, malignancy, and/or thrombosis. There may be no clear inciting event. The term superficial thrombophlebitis should be used when a thrombus has been diagnosed within the lumen of a superficial vein. Some prefer the term superficial venous thrombosis (SVT) instead of superficial thrombophlebitis to help limit confusion. In this brief article, superficial phlebitis (SP) and superficial thrombophlebitis (STP) will be used, and the discussion will be mostly limited to the lower extremity.
The common femoral vein begins once the external iliac vein passes below the inguinal ligament. The first branch of the common femoral vein is the greater saphenous vein, which comes off medially. The common femoral vein continues distally until it bifurcates into the profunda femoral vein and the superficial femoral vein (both of which are deep veins). The superficial femoral vein becomes the popliteal vein once within the adductor canal. The popliteal vein enters the popliteal fossa, and eventually trifurcates at the level of the popliteus muscle into the anterior tibial, posterior tibial, and peroneal veins. The greater saphenous vein runs the entire length of the leg, and passes anterior to the medial malleolus. The lesser saphenous vein arises from the popliteal vein and runs down the posterior calf, passing posterior to the lateral malleolus. There also are many perforating veins throughout the leg.
Superficial phlebitis of the lower extremity is quite common, and may result from various conditions. Patients who have venous stasis secondary to obesity, immobilization, and varicosities are all at an increased risk of superficial thrombophlebitis (STP). Pregnancy and the early postpartum period as well as thrombophilic states (e.g., antithrombin III deficiency and factor V Leiden deficiency) also predispose patients to the development of STP. Malignancy, particularly adenocarcinomas, have been well described in association with SP.
Unfortunately, all of these conditions also are risk factors for DVT and PE. It is for this reason that the general consensus is that patients who present with signs and symptoms of an SP or STP should be evaluated by some diagnostic test, usually ultrasound, to rule out underlying DVT. Any patient who presents with SP or STP and has respiratory symptoms or chest pain also should be evaluated for PE because patients who develop SP/STP often have other conditions that increase their risk for thromboembolic disease. Also, patients may have an STP that propagates into the deep venous system, thereby mandating anticoagulation therapy, and there are numerous reports in the literature where patients have an occult DVT that is not contiguous with the superficial clot and may even be present in the contralateral extremity. Reports also have been made of patients diagnosed with PE who had no DVT but rather superficial thrombosis only.
In general, once DVT has been ruled out, patients can be discharged with conservative management, including NSAIDs and compression stockings (not “Ted hose,” which do not generate enough compression). Patients should follow up with their primary doctor for repeat evaluation within 48 hours. If symptoms are not improving or if there are new symptoms suggestive of thromboembolic disease, repeat ultrasound, chest CT angiogram, or V/Q scan may be indicated.
Special mention should be made of STP of the greater saphenous vein. Any patient with a proximal saphenous vein thrombosis (proximal to the knee) must have a repeat ultrasound in two to five days. There is much debate about the proper management of proximal saphenous vein thrombosis. While some experts suggest timely re-evaluation with ultrasound, others recommend full anticoagulation therapy, particularly if the clot is near the femoral-saphenous junction. Of course, any extension into the femoral vein would require anticoagulation.
In the past, ligation with or without venous stripping was utilized when thrombus was present near the femoral-saphenous junction, but this has lost favor particularly because of the high risk for subsequent ileofemoral thrombosis. More recently, local transcatheter fibrinolysis has been employed. I believe the treatment needs to be tailored to each individual patient. One must consider the patient's risk factors for thromboembolic disease, whether there are modifications that can decrease the risk, and what risk there is to anticoagulation. Discussions with vascular surgery, hematology, and interventional radiology regarding risk versus benefit of each therapy will help direct the most appropriate therapy.
While this patient also was placed on oral antibiotics for a superficial cellulitis because it can be quite difficult to rule out, this is not to suggest that the patient had a suppurative (septic) thrombophlebitis. Patients with suppurative thrombophlebitis are usually quite ill with high fevers and purulent discharge along the course of a vein. These patients should receive intravenous broad spectrum antibiotics with an emergent vascular surgery consult because this condition most often requires surgical treatment.