Download PDF
Hamostaseologie 2013; 33(03): 232-240
DOI: 10.5482/HAMO-13-04-0027
Review
Schattauer GmbH

Diagnosis and treatment of superficial vein thrombosis

Diagnostik und Therapie der oberflächlichen Venen thrombose
R. M. Bauersachs
1   Medical Department IV, Max-Ratschow-Klinik für Angiologie, Klinikum Darmstadt
› Author Affiliations
Further Information

Publication History

received: 28 April 2013

accepted in revised form: 24 May 2013

Publication Date:
28 December 2017 (online)

Also available at
    Permissions and Reprints

Summary

Superficial vein thrombosis (SVT) is a common disease, characterized by an inflammatory- thrombotic process in a superficial vein. Typical clinical findings are pain and a warm, tender, reddish cord along the vein. Until recently, no reliable epidemiological data were available. The incidence is estimated to be higher than that of deep-vein thrombosis (DVT) (1/1000). SVT shares many risk factors with DVT, but affects twice as many women than men and frequently occurs in varicose veins. Clinically, SVT extension is commonly underestimated, and patients may have asymptomatic DVT. Therefore, ultrasound assessment and exclusion of DVT is essential. Risk factors for concomitant DVT are recent hospitalization, immobilization, autoimmune disorders, age > 75 years, prior VTE, cancer and SVT in non-varicose veins. Even though most patients with isolated SVT (without concomitant DVT or PE) are commonly treated with anticoagulation for a median of 15 days, about 8% experience symptomatic thromboembolic complications within three months. Risk factors for occurrence of complications are male gender, history of VTE, cancer, SVT in a non-varicose vein or SVT involving the sapheno-femoral junction (SFJ). As evidence supporting treatment of isolated SVT was sparse and of poor quality, the large, randomized, double-blind, placebocontrolled CALISTO trial was initiated assessing the effect of fondaparinux on symptomatic outcomes in isolated SVT. This study showed that, compared with placebo, 2.5 mg fondaparinux given for 45 days reduced the risk of symptomatic thromboembolic complications by 85% without increasing bleeding. Based on CALISTO and other observational studies, evidence-based recommendations can be made for the majority of SVT patients. Further studies can now be performed in higher risk patients to address unresolved issues.

Zusammenfassung

Die oberflächliche Venenthrombose (OVT) ist eine häufige Erkrankung, die durch einen inflammatorisch- thrombotischen Prozess in einer oberflächlichen Vene gekennzeichnet ist. Typische klinische Befunde sind ein überwärmter, schmerzhafter geröteter Strang entlang des Venenverlaufes und/oder eine eher flächenhafte Rötung und Überwärmung. Bis vor kurzem gab es keine zuverlässigen epidemiologischen Daten über Inzidenz, Prävalenz oder assoziierte Komplikationen. Die Inzidenz der OVT ist wahrscheinlich höher als die Inzidenz der tiefen Venenthrombose (1/1000). Die Risikofaktoren für das Auftreten einer OVT entsprechen denen der TVT und Lungenembolie (LAE), allerdings betrifft die OVT doppelt so viele Frauen als Männer und sie tritt häufig in varikösen Venen auf. Bei der klinischen Untersuchung wird die Ausdehnung der OVT häufig unterschätzt, und Patienten mit OVT können gleichzeitig eine asymptomatische TVT aufweisen. Eine Ultraschalluntersuchung der OVT zur Dokumentation der Thrombusausdehnung und zum Ausschluss einer TVT ist daher essenziell. Risikofaktoren für das Auftreten einer gleichzeitigen TVT sind kürzlicher Krankenhausaufenthalt, Immobilisation, Auto immunerkrankungen, Alter über 75 Jahre oder Zustand nach stattgehabten venösen Thromboembolien (VTE), Tumorleiden oder eine OVT in nicht-varikös veränderten Venen. Patienten mit einer isolierten OVT, d. h. ohne gleichzeitige TVT oder LAE, werden häufig mit einer Antikoagulation über eine mediane Dauer von 15 Tagen behandelt, und erleiden trotz dieser Therapie in 8% symptomatische thromboembolische Komplikationen in den ersten drei Monaten. Risikofaktoren für das Auftreten solcher Komplikationen sind männliches Geschlecht, eine VTE-Vorgeschichte, Tumorleiden, OVT in einer nicht varikösen Vene oder Ausdehnung der OVT bis in die Krosse. Die bisher vorliegende Evidenz zur Therapie der isolierten OVT ist schwach, und die methodische Qualität der verfügbaren Studien schlecht. Daher wurde eine große, randomisierte doppelblinde, Placebo-kontrollierte Studie (CALISTO) initiiert, um den Effekt einer Antikoagulation mit Fondaparinux, auf das Auftreten von klinischen, symptomatische Endpunkten bei Patienten mit isolierter OVT zu untersuchen. Die Studie zeigte, dass 2,5 mg Fondaparinux s. c. über 45 Tage im Vergleich zu Placebo das Risiko von symptomatischen thromboembolischen Komplikationen um 85% reduziert, ohne einen Anstieg des Blutungsrisikos.

Basierend auf den Ergebnissen von CALISTO und anderen Beobachtungsstudien können für die Mehrzahl der OVT-Patienten evidenzbasierte Empfehlungen gegeben werden, weitere Studien können auf Basis dieser Ergebnisse auch in Hochrisikokollektiven durchgeführt werden, um ungeklärte Fragen im OVT-Management zu beantworten.

Keywords

Superficial vein thrombosis - review - epidemiology - diagnosis - treatment

Schlüsselwörter

Oberflächliche Venenthrombose - Übersicht - Epidemiologie - Diagnostik - Behandlung
 

  • References

  • 1 Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSAPS). Recommandations de bonne pratique. Prévention et traitement de la maladie thromboembolique veineuse en médecine. Recommandations. http://ansm.sante.fr/var/ansm_site/storage/original/application/ae4209ebc36d7164d4b7c876ddeaabab.pdf Accessed 18 April 2009.
    PubMedGoogle Scholar
  • 2 Belcaro G, Nicolaides AN, Errichi BM. et al. Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study. Angiology 1999; 50: 523-529.
    CrossrefPubMedGoogle Scholar
  • 3 Cesarone MR, Belcaro G, Agus G. et al. Management of superficial vein thrombosis and thrombophlebitis: status and expert opinion document. Angiology 2007; 58 (Suppl. 01) 7S-15S.
    CrossrefPubMedGoogle Scholar
  • 4 De Maeseneer MGR. on behalf of the Thrombosis Guidelines Group of the Belgium Society on Thrombosis and Haemostasis and the Belgian Working Group on Angiology. Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment. Acta Chir Belg 2005; 105: 145-147.
    CrossrefPubMedGoogle Scholar
  • 5 Decousus H, Epinat M, Guillot K. et al. Superficial vein thrombosis: risk factors, diagnosis, and treatment. Curr Opin Pulm Med 2003; 09: 393-397.
    CrossrefPubMedGoogle Scholar
  • 6 Decousus H, Frappe P, Accassat S. et al. Epidemiology, diagnosis, treatment and management of superficial-vein thrombosis of the legs. Best Pract Res Clin Haematol 2012; 25: 275-284.
    CrossrefPubMedGoogle Scholar
  • 7 Décousus H, Leizorovicz A, Bauersachs R. et al. Fondaparinux for the treatment of superfical-vein thrombosis in the legs N Engl J Med. 2010; 363: 1222-1232.
    PubMedGoogle Scholar
  • 8 Decousus H, Quere I, Presles E. et al. Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med 2010; 152: 218-224.
    CrossrefPubMedGoogle Scholar
  • 9 Decousus H, Bertoletti L, Frappé P. et al. Recent findings in the epidemiology, diagnosis and treatment of superficial-vein thrombosis. Thromb Res 2011; 127 (Suppl. 03) S81-S85.
    CrossrefPubMedGoogle Scholar
  • 10 Di Minno G, Mannucci PM, Tufano A. et al. The first ambulatory screening on thromboembolism: a multicentre, cross-sectional, observational study on risk factors for venous thromboembolism. J Thromb Haemost 2005; 03: 1459-1466.
    CrossrefPubMedGoogle Scholar
  • 11 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2007: CD004982.
    PubMedGoogle Scholar
  • 12 Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2012 03. CD004982.
    PubMedGoogle Scholar
  • 13 Galanaud JP, Bosson JL, Genty C. et al. Superficial vein thrombosis and recurrent venous thromboembolism: a pooled analysis of two observational studies. J Thromb Haemost 2012; 10: 1004-1011.
    CrossrefPubMedGoogle Scholar
  • 14 Galanaud JP, Genty C, Sevestre MA. et al. Predictive factors for concurrent deep-vein thrombosis and symptomatic venous thromboembolic recurrence in case of superficial venous thrombosis. The OPTIMEV study. Thromb Haemost 2011; 105: 31-39.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Goldman L, Ginsberg J. Superficial phlebitis and phase 3.5 trials. N Engl J Med 2010; 363: 1278-1280.
    CrossrefPubMedGoogle Scholar
  • 16 Hafner CD, Cranley JJ, Krause RJ, Strasser ES. A Method of Managing Superficial Thrombophlebitis. Surgery 1964; 55: 201-206.
    PubMedGoogle Scholar
  • 17 Husni EA, Williams WA. Superficial thrombophlebitis of lower limbs. Surgery 1982; 91: 70-74.
    PubMedGoogle Scholar
  • 18 Jeanneret C, Brunner S. Superficial venous thrombosis. A review. Hautarzt 2012; 63: 609-615.
    CrossrefPubMedGoogle Scholar
  • 19 Jeanneret C, Baldi T, Jenelten R. La thrombophlébite superficielle: une vue d’ensemble. Recommandé/accrédité par la Société Suisse de Médecine Générale et la Société Suisse de Médecine Interne. Forum Médical Suisse 2006; 06: 190-195.
    PubMedGoogle Scholar
  • 20 Kearon C, Kahn SR, Agnelli G. et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (8th ed). Chest 2008; 133 (Suppl. 06) 454S-545S.
    CrossrefPubMedGoogle Scholar
  • 21 Kearon C. Extended anticoagulation for unprovoked venous thromboembolism: a majority of patients should be treated. J Thromb Thrombolysis 2011; 31: 295-300.
    CrossrefPubMedGoogle Scholar
  • 22 Leizorovicz A, Prandoni P, Decousus H. on behalf of the Steering Committee of the CALISTO Study. Fondaparinux reduces all types of symptomatic thromboembolic complications in patients with superficial-vein thrombosis in the legs: data from the CALISTO study. Blood 2011; 118: 2310.
    PubMedGoogle Scholar
  • 23 Leon L, Giannoukas AD, Dodd D, Chan P, Labropoulos N. Clinical significance of superficial vein thrombosis. Eur J Vasc Endo-vasc Surg 2005; 29: 10-17.
    CrossrefPubMedGoogle Scholar
  • 24 Lozano FS, Almazan A. Low-molecular-weight heparin versus saphenofemoral disconnection for the treatment of above-knee greater saphenous thrombophlebitis: a prospective study. Vasc Endovascular Surg 2003; 37: 415-420.
    CrossrefPubMedGoogle Scholar
  • 25 Lutter KS, Kerr TM, Roedersheimer LR. et al. Superficial thrombophlebitis diagnosed by duplex scanning. Surgery 1991; 110: 42-46.
    PubMedGoogle Scholar
  • 26 Marchiori A, Verlato F, Sabbion P. et al. High versus low doses of unfractionated heparin for the treatment of superficial thrombophlebitis of the leg. A prospective, controlled, randomized study. Haematologica 2002; 87: 523-527.
    PubMedGoogle Scholar
  • 27 Partsch H, Mostbeck A. Lungenembolien bei oberflächlicher Thrombophlebitis?. Acta med Austr 1979; 06: 159.
    PubMedGoogle Scholar
  • 28 Plate G, Eklof B, Jensen R, Ohlin P. Deep venous thrombosis, pulmonary embolism and acute surgery in thrombophlebitis of the long saphenous vein. Acta Chir Scand 1985; 151: 241-244.
    PubMedGoogle Scholar
  • 29 Prandoni P, Casiglia E, Tikhonoff V. et al. Calisto Investigators. The risk of subsequent cancer and arterial cardiovascular events in patients with superficial vein thrombosis in the legs. Blood 2011; 118: 4719-4722.
    CrossrefPubMedGoogle Scholar
  • 30 Quenet S, Laroche JP, Bertoletti L. et al. Value of a planned compression ultrasonography after an isolated superficial vein thrombosis: results from a prospective multicentre study. Eur J Vasc Endo-vasc Surg 2012; 43: 233-237.
    CrossrefPubMedGoogle Scholar
  • 31 Quéré I, Decousus H, Leizorovicz A. Risk Factors For Concomitant Venous Thromboembolism (VTE) In Patients With Superficial Thrombophlebitis (ST): Preliminary Results Of The POST Study. J Thromb Haemost 2007; 05 (Suppl. 02) P-S-600.
    CrossrefPubMedGoogle Scholar
  • 32 Rabe E, Bauersachs R, Pannier F. Dalteparin in patients with superficial leg vein thrombophlebitis (SVT) in addition to compression treatment – a placebo-controlled phase III study. 50 Union Int Phlebologie, Monaco 2009
    PubMedGoogle Scholar
  • 33 Sorensen HT, Svaerke C, Farkas DK. et al. Superficial and deep venous thrombosis, pulmonary embolism and subsequent risk of cancer. Eur J Cancer 2012; 48: 586-593.
    CrossrefPubMedGoogle Scholar
  • 34 Talbot SR. B-mode evaluation of peripheral veins. Semin Ultrasound CT MR 1988; 09: 295-319.
    PubMedGoogle Scholar
  • 35 The Stenox Study Group. A pilot randomized double-blind comparison of a low-molecularweight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis. Arch Intern Med 2003; 163: 1657-1663.
    CrossrefPubMedGoogle Scholar
  • 36 The Vesalio Investigators Group. High vs. low doses of low-molecular-weight heparin for the treatment of superficial vein thrombosis of the legs: a double-blind, randomized trial. J Thromb Haemost 2005; 03: 1152-1157.
    CrossrefPubMedGoogle Scholar
  • 37 Titon JP, Auger D, Grange P. et al. Therapeutic management of superficial venous thrombosis with calcium nadroparin. Dosage testing and comparison with a non-steroidal anti-inflammatory agent. Ann Cardiol Angeiol (Paris) 1994; 43: 160-166.
    PubMedGoogle Scholar
  • 38 Van Langevelde K, Lijfering WM, Rosendaal FR, Cannegieter SC. Increased risk of venous thrombosis in persons with clinically diagnosed superficial vein thrombosis: results from the MEGA study. Blood 2011; 118: 4239-4241.
    CrossrefPubMedGoogle Scholar
  • 39 Verlato F, Zucchetta P, Prandoni P. et al. An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh. J Vasc Surg 1999; 30: 1113-1115.
    CrossrefPubMedGoogle Scholar
  • 40 Wichers IM, Haighton M, Buller HR, Middeldorp S. A retrospective analysis of patients treated for superficial vein thrombosis. Neth J Med 2008; 66: 423-427.
    PubMedGoogle Scholar
  • 41 Widmer L. Venenkrankheiten, Häufigkeit und sozialmedizinische Bedeutung. Bern: Hans Huber; 1978
    Google Scholar
  • 42 Widmer LK, Leu HJ, Breil H. On the epidemiology of venous diseases, 2nd Basel study. Zentralbl Phlebol 1967; 06: 257-264.
    PubMedGoogle Scholar