What is Superficial Thrombophlebitis?
Superficial thrombophlebitis is a condition that causes inflammation and blood clotting in the veins just underneath your skin. It often affects the veins in the lower parts of your body, particularly those in the leg known as the great saphenous vein (affecting 60% to 80% cases) or the small or short saphenous vein (affecting 10% to 20% cases). However, this condition can also occur in other parts of the body (in 10% to 20% cases) and in some cases, can affect both sides of the body (in 5% to 10% cases).
In the past, superficial thrombophlebitis, also known as superficial venous thrombosis (SVT), was thought to be a relatively harmless condition that would go away on its own. But recent understandings indicate it can be connected to more serious blood clot disorders, like deep venous thrombosis (DVT), which is a clot in a deeper vein, and pulmonary embolism (PE), which is a blockage in one of the pulmonary arteries in your lungs. As a result, managing this condition may require more than just supportive care; it may also need a thorough medical diagnosis.
People with superficial thrombophlebitis or SVT also face a higher risk of experiencing repeated episodes of blood clotting events. Thus, in this context, the terms superficial thrombophlebitis and SVT mean the same thing and can be used interchangeably.
What Causes Superficial Thrombophlebitis?
There are a few factors that can increase the risk of superficial venous thrombosis (SVT), which is the condition where a blood clot forms just under the surface of your skin. This could be due to a state where your blood is thicker and prone to clotting, staying in one place for a long time, or injury to a blood vessel wall.
It’s worth mentioning that SVT accounts for about 5.4% of risks for deep vein thrombosis (DVT) or pulmonary embolism (PE), which are more serious conditions where blood clots form deeper within your veins or travel to your lungs respectively.
Some inherited conditions that make forming blood clots likely can actually show up initially as SVT. For instance, SVT occurs in 11-15% of patients who lack certain proteins that stop blood clots, and about 40% of those with a genetic change known as factor V Leiden mutation. Though, not all studies agree on these statistics.
In pregnancy, the risk of SVT is similar to that of DVT, particularly after childbirth. Other potential risk factors for SVT include old age, using estrogen medication, autoimmune or infectious diseases, obesity, recent injury or surgery, active cancer, history of blood clots, and heart or lung failure.
Previous cases of SVT increase the risk of future ones. Varicose veins, which are swollen, twisted veins that you can see just under the skin, are thought to be the most common identifiable risk factor for SVT in 75-88% of cases.
Risk Factors and Frequency for Superficial Thrombophlebitis
Superficial thrombophlebitis (SVT) is a condition whose true occurrence rate is not well-known. Some studies report different levels of occurrence. For instance, one survey in France discovered a SVT incidence rate of 0.64%. Another study suggested that SVT may be half as common as another condition known as deep vein thrombosis (DVT), but similarly prevalent as pulmonary embolism (PE). Furthermore, other research suggests SVT could be 2 to 6 times more common than DVT and PE.
- SVT is usually observed in outpatients, especially women representing 50% to 70% of impacted patients in one study.
- On average, patients are around 60 years old.
- People with a body mass index over 25 kg/m2 and those with varicose veins are more likely to experience SVT.
Additionally, for individuals who have had SVT before, the lifetime risk of developing DVT or PE increases four to six times. Despite this, the death rate within three months of diagnosis is much lower for patients with SVT (less than 1%) compared to those with DVT or PE (about 5%). It is suggested that SVT patients usually have a lower death rate because they tend to be younger and have fewer additional health issues. SVT can lead to DVT or PE if the blood clot moves towards the deep veins at specific junctions of the leg, or from a perforating vein during a state of increased blood clotting.
Signs and Symptoms of Superficial Thrombophlebitis
Superficial thrombophlebitis is a condition where a vein close to the surface of the skin becomes inflamed, causing the area over it to turn red, become warm, and tender. Patients with this condition often feel a hard or “cord” like structure under their skin, and some may even experience swelling and itching around the area. Please note that if there is a lot of swelling in your limb, it could represent a more serious condition called Deep Vein Thrombosis (DVT), so it’s important to get it checked out.
Patients with superficial thrombophlebitis might have a history of injury or specific medical treatments. For instance, having experienced a recent vein injury, received intravenous drugs, or undergone a procedure to treat varicose veins could potentially think of having this condition.
People over 40 who don’t have any other risk factors for vein inflammation should consider the possibility of an underlying cancer if they have superficial thrombophlebitis. Also, if the inflammation keeps moving or changing places (a condition known as migratory thrombophlebitis), this too could be a sign of an underlying cancer. Migratory thrombophlebitis is particularly linked with pancreatic and other types of abdominal cancers, and can sometimes be the first sign of these cancers in a small percentage of patients.
The following are the signs and symptoms of superficial thrombophlebitis:
- Red, warm, inflamed, tender skin area above a superficial vein
- Presence of a palpable cord
- Possible surrounding edema (swelling) or Pruritis (itching)
- Patients may report history of injury or medical treatments such as intravenous drug usage or recent varicose vein treatment
- If over 40 and no other risk factors, consider underlying malignancy
- Patients with migratory thrombophlebitis should also be screened for underlying malignacy
Testing for Superficial Thrombophlebitis
Superficial thrombophlebitis, a condition which involves a blood clot forming in a superficial vein, was traditionally diagnosed based on signs and symptoms. However, doctors have recognized that it can be linked to more serious issues, like deep vein thrombosis (DVT), where a clot forms in a deep vein, or pulmonary embolism (PE), which is a blockage in one of the lung’s arteries. Therefore, they often use compressive ultrasonography, a type of imaging test that creates detailed pictures of the veins, to confirm the diagnosis and evaluate the blood clot’s size and location.
Physical examinations, while still important, are not always accurate in determining the full extent of the disease. In fact, up to 77% of the time, these exams underestimate the size and extent of the problem. An ultrasound can help doctors confirm the diagnosis, figure out the size of the clot, and, crucially, see if more serious conditions like DVT are present.
A study called the Prospective Observational Superficial Thrombophlebitis (POST) showed using ultrasound revealed that nearly one in four patients had concurrent DVT. More than half of these DVTs were not connected to the superficial vein thrombosis (SVT), and 17% were in the opposite leg. Only 1% was found only in the opposite leg. These findings have led to more frequent use of ultrasounds for evaluating SVT.
The same study found that if a vein that communicates between a superficial
and a deep vein was involved, or an SVT was located less than 3 cm from a major junction of veins in the leg, the risk of associated DVT significantly increased.
Testing for a substance in the blood called D-dimer, which is typically high when a clot is present, is not very helpful in diagnosing SVT. The levels of this substance vary too much in SVT patients to use it to distinguish between SVT and DVT.
At present, there is no strong evidence to suggest people presenting with SVT without any known cause should be screened for a higher risk of developing blood clots. However, patients over the age of 40 experiencing their first episode of thrombophlebitis should be checked for the possibility of cancer. In particular, patients with superficial thrombophlebitis in the veins of the breast, a condition known as Mondor disease, may need to be screened for breast cancer since there may be some association. Despite a study that suggested a 12.7% risk of breast cancer in these patients, it was a limited study, so the actual risk may not be as high.
The Internal Carotid Artery Occlusion (ICARO) Study Group suggested a scoring system to estimate the likelihood of DVT in patients with SVT. The system gives points based on factors like having an active cancer, swelling in the leg, patient’s age, physical signs of a clot, and the cause of SVT. Although this system is used, recent studies have questioned its validity.
Treatment Options for Superficial Thrombophlebitis
There’s ongoing debate about the best treatment for superficial thrombophlebitis, a condition where a blood clot forms in a vein near the surface of the skin. Various approaches have been suggested to manage the symptoms and reduce the risk of the blood clot spreading or leading to a pulmonary embolism, a serious condition where a blood clot travels to the lungs.
For low-risk cases, where there’s no risk or history of blood clot-related diseases, the common consensus is to use treatments like nonsteroidal anti-inflammatory drugs (painkillers that reduce inflammation), applying heat, and anticoagulants (drugs that prevent blood clots).
People with a higher risk of complications include those with a superficial vein thrombosis (SVT) in the lower leg that’s at least 5 cm long, an SVT above the knee which is especially close to the saphenofemoral junction (where the saphenous vein joins with the femoral vein), severe symptoms, involvement of the great saphenous vein (the largest vein in your leg), a history of SVT or vein-related blood clot diseases, an active cancer diagnosis, or recent surgery.
According to a review by Cochrane in 2018, these higher-risk patients should receive fondaparinux, an anticoagulant. This review also looked at topical treatments (applied to the skin) and surgical options, but found that there’s not enough evidence on these methods and their effects on blood clot-related diseases yet, so more research is recommended.
A trial showed that using the drug rivaroxaban for 45 days had a similar safety profile and was just as effective as fondaparinux in preventing complications, but the Cochrane review highlighted that more research is needed on its use and other similar drugs. Additionally, we still need more studies on the use of nonsteroidal anti-inflammatory drugs and a certain type of anticoagulant called low molecular weight heparins.
There’s no consensus recommendation on the safety, dose, or therapy duration for topical treatments, nonsteroidal anti-inflammatory drugs, or systemic anticoagulation in patients who develop superficial thrombophlebitis from an infusion, a method of delivering drugs into a vein. The general practice in the United Kingdom suggests using compression stockings along with other therapies, but there’s no current recommendation for or against their use in the United States. Antibiotics are only used if there’s a clear infection present.
For a condition called Trousseau syndrome, the main goal is to treat the underlying cancer causing the condition. This is often challenging, so heparin, a type of anticoagulant, is usually used as the preferred treatment. Other drugs have been tried, but were found to be less effective. A case report suggested first treating with heparin followed by oral anticoagulants.
Finally, Mondor disease, commonly self-limiting and benign, normally goes away on its own within 4 to 8 weeks. But if it’s caused by inflammation of the blood vessels, cancer, or a condition that makes your blood clot more easily, treatment is aimed at these underlying causes.
What else can Superficial Thrombophlebitis be?
When a doctor is examining a patient, they should consider several possible diagnoses. One such possibility is a condition called superficial thrombophlebitis. But, there are many other conditions that can present similarly:
- Cellulitis, a common skin infection
- Venous thromboembolic diseases, conditions related to abnormal blood clotting
- Hematoma, a collection of blood outside the blood vessels
- Lymphangitis, inflammation of the lymphatic channel
- Lymphedema, swelling caused by blockages in the lymphatic system
- Vasculitis, inflammation of the blood vessels
- Tendonitis or sports-related injuries
- And venous insufficiency, a condition where the blood does not flow up from the legs to the heart properly
The doctor should keep all these conditions in mind to ensure an accurate diagnosis.
What to expect with Superficial Thrombophlebitis
The outlook for Superficial thrombophlebitis, which is a condition where blood clots form in veins near the skin’s surface, depends on what caused it. For low-risk cases, the outlook is usually positive, but there’s a chance the problem could return. If you have a high-risk version of this condition, the outlook can also be positive if you receive the right treatment. If the cause of Superficial thrombophlebitis is a serious disease like cancer, the outlook is associated with that underlying disease.
Possible Complications When Diagnosed with Superficial Thrombophlebitis
Deep vein thrombosis (DVT) and pulmonary embolisms (PE) are significant risks when dealing with superficial thrombophlebitis (SVT), which is an inflammation of the veins just below the skin surface. Various studies have found that DVT happens along with SVT in 6-36% of patients. Also, 2-13% of these studies suspected PE at the same time. Lung scans revealed that asymptomatic PE, which is a PE that doesn’t show symptoms, can happen in about one-third of the patients.
Furthermore, other studies looking back at past data have reported that 25-30% of patients initially presented with DVT or symptomatic PE, which means they showed signs of PE. Of these patients, 5-7% were found to have symptomatic PE. Interestingly, when asymptomatic patients were screened more diligently, the number of detected PE increased to 17%.
Patients with a blood clot or thrombus present up to 3 cm from the saphenofemoral junction, which is where the saphenous vein and femoral vein meet, should be treated for DVT. This is because 14-70% of such cases are found to progress to DVT, which is a serious condition involving a blood clot in the deep veins, most commonly in the leg.
Common Risks:
- Deep vein thrombosis with superficial thrombophlebitis: 6-36%
- Simultaneous pulmonary embolism suspicion: 2-13%
- Asymptomatic pulmonary embolism on lung scans: up to 33%
- Deep vein thrombosis or symptomatic pulmonary embolism on first presentation: 25-30%
- Detection of symptomatic pulmonary embolism: 5-7%
- Increased detection of pulmonary embolism with rigorous screening: 17%
- Need for DVT treatment due to thrombus near saphenofemoral junction: 14-70%
Preventing Superficial Thrombophlebitis
Patients should be informed about the possibility and importance of their illness spreading or coming back, depending on their individual risk factors. If they notice the occurrence of a condition known as migratory thrombophlebitis, which is the shifting or migration of painful blood clots in their veins, they should seek further health assessment. Also, patients who are older than 40 years when they first show signs of the illness, and have no other risk factors for a condition called venous thromboembolic disease – a condition where blood clots form in the veins that can be dangerous, should also seek further examination.
