Management Of Superficial Thrombophlebitis

A 65-year-old woman presents with painful, red skin on the inside of her thigh. This has developed over the past 4-5 days and has not happened before. She is normally fit and well and no past medical history of note other than depression.
On examination she has erythematous, tender skin on the medial aspect of her right thigh consistent with the long saphenous vein. The vein is palpable and cord-like. There is no associated swelling of the right calf and no history of chest pain or dyspnoea.
Heart rate is 84/min and her temperature is 37 C.

What is the most appropriate management?

A. Prescribe an oral NSAID
B. Prescribe a topical NSAID
C. Refer for an ultrasound scan
D. Prescribe a topical heparinoid
E. Prescribe an oral NSAID and oral flucloxacillin

Answer:
C. Refer for an ultrasound scan

Discussion : It is recommended to refer patients with long saphenous vein superficial thrombophlebitis for an ultrasound scan to exclude an underlying DVT.

Superficial Thrombophlebitis 
Superficial thrombophlebitis, as the name suggests describes the inflammation associated with thrombosis of one of the superficial veins, usually the long saphenous vein of the leg.
This process is usually non-infective in nature but secondary bacterial infection may rarely occur resulting in septic thrombophlebitis. Around 20% with superficial thrombophlebitis will have an underlying deep vein thrombosis (DVT) at presentation and 3-4% of patients will progress to a DVT if untreated.
The risk of DVT is partly linked to the length of vein affected - an inflammed vein > 5 cm is more likely to have an associated DVT.

Management 
There are currently a variety of treatment approaches to superficial thrombophlebitis.

• Traditionally NSAIDs have been used, with topical NSAIDs for limited and mild disease and oral NSAIDs for more severe disease. 
• Topical heparinoids have also be used in the management of superficial thrombophlebitis.

A Cochrane review however found topical NSAIDs and heparinoids have no significant benefit in terms of reducing extension or progression to DVT. Oral NSAIDs were however shown to reduce the risk of extension by 67%.

Compression stockings are also used. Remember that the ankle-brachial pressure index (ABPI) should be measured before prescribing compression stockings, particularly if using class 2 or above stockings.

One of the major changes to the management of superficial thrombophlebitis is the increased use of low-molecular weight heparin. This has been shown to reduce extension and transformation to DVT.

SIGN produced guidelines in 2010: Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT.
 Patients with superficial thrombophlebitis should have anti-embolism stockings and can be considered for treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
 If LMWH is contraindicated, 8-12 days of oral NSAIDS should be offered. Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks. This may be a significant departure from our current practice - the majority of patients with superficial thrombophlebitis (i.e. those affecting the long saphenous vein) should be referred for an ultrasound scan.