Phlebology > Volume 23, Number 6 > Pp. 299

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Letter

Treatment of superficial thrombophlebitis of the great saphenous vein

Marianne De Maeseneer 

Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Belgium

Email: marianne.demaeseneer{at}ua.ac.be

I read with interest the article by Hill et al.¹ on superficial thrombophlebitis (ST) of the great saphenous vein (GSV). Based on the data of a retrospective analysis of lower extremity venous duplex scans carried out from 2004–2005, they recommend careful follow-up with repeat duplex scans to determine if there is propagation of the thrombus, and if thrombus is extending to within 5 cm of the saphenofemoral junction, to start full anticoagulation and/or surgical intervention.

The authors correctly state that ascending ST is a serious illness as it may lead to deep vein thrombosis (DVT) and even pulmonary embolism. Therefore, duplex scan is mandatory to evaluate the extension of the thrombus and to detect a (non-) contiguous DVT. However, the initial strategy suggested by the authors – which is a vigorous treatment with heat, limb elevation, non-steroidal medications and antibiotics – is certainly open for discussion.

First, the advice for bed rest and leg elevation in patients with ST is rather surprising since this constitutes an ideal method to further promote extension of the thrombus into the deep vein. Indeed, in the study of Hill et al.¹ the follow-up duplex scan revealed cephalad progression of the thrombus to occur in 17 of 30 patients with ST of the GSV, and in eight patients there was extension of the thrombus into the common femoral vein. It is well known that bed rest and immobilization are major risk factors for venous thromboembolism due to venous stasis, one of the most important elements of Virchow's triad. Venous stasis should by all means be avoided when there is already a thrombus in the superficial venous system. Moreover, mobilization might enhance fibrinolytic activity with reduction of thrombus. Therefore, the Belgian Thrombosis Guidelines Group (TGG) recommended immediate mobilization with elastic compression in all patients with ST.²

Secondly, thrombophlebitis is not caused by infection and therefore antibiotic treatment is completely unnecessary (except in rare cases of septic thrombophlebitis).³ Moreover, local heat is not indicated and patients with ST will benefit much more from local application of a cold-pack to reduce the local inflammatory signs.

Thirdly, it is surprising that in the discussion of this paper initial treatment of extensive ST of the GSV with low molecular weight heparin (LMWH) is not discussed, although several recent papers (mainly from Europe) suggest that the latter treatment might be efficacious. The use of intermediate dosages of unfractionated heparin or LMWH for at least four weeks is recommended in the ACCP guidelines (Grade 2B), as well as in the TGG guidelines and in a recently published Cochrane Review on treatment of ST.^2,4,5

	References

Top References

 

1. Hill SL, Hancock DH, Webb TL. Thrombophlebitis of the great saphenous vein – recommendations for treatment. Phlebology 2008;23:35–9[Abstract/Free Full Text]
2. De Maeseneer MG and Thrombosis Guidelines Group of the Belgian Society on Thrombosis and Haemostasis and Belgian Working Group on Angiology. Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment. Acta Chir Belg 2005;105:145–7[Medline]
3. Campbell B. Clinical review. Varicose veins and their management. Br Med J 2006;333:287–92[Free Full Text]
4. Büller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease. The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004;126(suppl.):401S–28S[Medline]
5. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2007, Issue 2. Art. No: CD004982; DOI: 10.1002/14651858. CD004982.pub3

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by De Maeseneer, M. Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?