Superficial venous thrombosis
Superficial venous thrombosis is inflammation and clotting in a superficial vein, usually in the arms or legs. Short-term venous catheterization of superficial arm veins as well as the use of longer-term peripherally inserted central catheter (PICC) lines are the most common cause of superficial thrombophlebitis. Intravenous catheter sites should be observed daily for signs of local inflammation and should be removed if a local reaction develops in the vein. Serious thrombotic or septic complications can occur if this policy is not followed; Staphylococcus aureus is the most common pathogen. Other organisms, including fungi, may also be responsible.
Superficial thrombophlebitis may occur spontaneously, often in pregnant or postpartum women or in individuals with varicose veins, or it may be associated with trauma, as with a blow to the leg or following intravenous therapy with irritating solutions. It also may be a manifestation of systemic hypercoagulability secondary to abdominal cancer such as carcinoma of the pancreas and may be the earliest sign of these conditions. Superficial thrombophlebitis may be associated with occult DVT in about 20% of cases. Pulmonary emboli are exceedingly rare and occur from an associated DVT.
Symptoms of Superficial Venous Thrombosis
Pain and swelling develop rapidly in the area of inflammation. The skin over the vein becomes red, and the area feels warm and is very tender. Because blood in the vein is clotted, the vein feels like a hard cord under the skin, not soft like a normal or varicose vein. The vein may feel hard along its entire length.
For spontaneous thrombophlebitis if the process is well localized and not near the saphenofemoral junction, local heat and nonsteroidal anti-inflammatory medications are usually effective in limiting the process. If the induration is extensive or is progressing toward the saphenofemoral junction (leg) or cephalo-axillary junction (arm), ligation and division of the vein at the junction of the deep and superficial veins is indicated.
Anticoagulation therapy is usually not required for focal processes. Prophylactic dose low-molecular-weight heparin or fondaparinux is recommended for 5 cm or longer superficial thrombophlebitis of the lower limb veins and full anticoagulation is reserved for disease that is rapidly progressing or if there is concern for extension into the deep system.
Septic superficial thrombophlebitis is an intravascular abscess and requires urgent treatment with heparin or fondaparinux to limit additional thrombus formation as well as removal of the offending catheter in catheter-related infections. Treat with antibiotics (eg, vancomycin, 15 mg/kg intravenously every 12 hours plus ceftriaxone, 1 g intravenously every 24 hours). If cultures are positive, therapy should be continued for 7–10 days or for 4–6 weeks if complicating endocarditis cannot be excluded. Surgical excision of the involved vein may also be necessary to control the infection.