51: ACUTE SUPERFICIAL VENOUS THROMBOSIS: EVALUATION AND TREATMENT

PATIENT STORY

A 74-year-old man presents with acute erythema, pain, and tenderness along the medial aspect of his thigh and knee. He was recently hospitalized with proximal calf cellulitis, but the pain and distribution of these clinical findings are different. He has a history of calf deep venous thrombosis (DVT) approximately 10 years ago. Duplex ultrasound demonstrates thrombus within the great saphenous vein (GSV). He is initially managed conservatively with nonsteroidal agents. On repeat duplex ultrasound, he is found to have proximal propagation into the common femoral vein junction. Anticoagulation is initiated for approximately 3 months. He does well and ultimately undergoes GSV ablation.

EPIDEMIOLOGY

Superficial Venous Thrombosis

• Affects approximately 125,000 people in the United States per year, but the true annual incidence is likely unknown due to under-recognition and under-reporting.

• Is reported in approximately 3% to 11% of the population.¹

• Occurs more frequently in women than in men.

• Increases with age; mean age of presentation is 60 years.²

• Is associated with clinical features of obesity, immobility, and varicose veins.

• Occurs most commonly in the GSV (60%-80% of cases); the small saphenous vein and tributary varicosities are less frequently involved.

• Is associated with concomitant DVT in up to 40% of patients at the time of diagnosis.³

• Is associated with symptomatic pulmonary embolism (PE) in up to 12% of patients.³

Upper Extremity SVT

• Differs from lower extremity SVT in that it is frequently associated with an indwelling catheter (PICC) or device.

• Is usually related to the size and location of the indwelling device.

ETIOLOGY AND PATHOPHYSIOLOGY

Superficial venous thrombosis (SVT), also referred to as thrombophlebitis, typically has both thrombotic and inflammatory components.

• Inflammatory changes without thrombosis are termed as phlebitis.

• 60% to 80% of cases have associated varicose veins.

• There are common associations with external vein trauma, internal vein trauma, hemorheologic changes, and vein inflammation.⁴

• The role of thrombophilia has not been well defined, but prothrombotic conditions such as myeloproliferative disorders or underlying malignancy should be considered.^1,4

Lower Extremity SVT

• Is associated with prolonged immobilization, obesity, trauma, oral contraceptives and hormonal therapy, malignancy, inflammatory stimuli, autoimmune disease or vasculitis, and thromboangiitis obliterans.⁴

Upper Extremity SVT

• Is usually related to indwelling catheters, phlebotomy, or intravenous infusion.

DIAGNOSIS

Clinical Findings

• Patients typically present with warmth, erythema, induration, and tenderness along the vein (Figure 51-1).^1,4

• A palpable cord or thrombus within the vein is the most identifiable clinical finding.

• The pain may be out of proportion to the clinical findings.

• Patients may have associated varicose veins or skin changes of chronic ...