Management of superficial vein thrombosis and thrombophlebitis : status and expert opinion document

Superficial vein thrombosis (SVT) is characterised by clotting of superficial veins (i.e. following direct trauma) with minimal inflammatory component. Superficial thrombophlebitis (STPh) is a minimally-thrombotic process of superficial veins associated with inflammatory changes and/or infection. Two kinds of SVT/STPh can be defined: one is the ‘causal’ one associated to a visible cause (immobilisation, varicose veins trauma). The second one (non-causal SVT/STPh or ‘out-of-the-blue’ SVT/STPh) occurs without identifiable causes and may be an early sign of an unknown neoplastic or systemic disease. Diagnosis is made by ultrasound also excluding deep venous thrombosis (DVT). Treatments include analgesics, elastic compression (bandages-stockings), anti-inflammatory agents, local heath, exercise and ambulation and, in some cases, with local or systemic anticoagulants (concomitant DVT). It is better to avoid immobilisation. Topical analgesia with non-steroidal, anti-inflammatory creams (e.g. diclofenac cream and plasters) applied locally to the SVT/TVPh area control symptoms. Hirudoid cream (heparinoid) shortens the duration of signs/symptoms. Locally acting anticoagulants (Viatromb, spray Na-heparin) have positive effects on pain and on the reduction in thrombus size. Anti-thrombotic, compression stockings and bendages should be used considering tolerability which may be decreased in painful areas. Compression controls signs/symptoms and act as prophylaxis against DVT. Risk factors for SVT should be removed or limited. Varicose veins surgery becomes urgent if thrombi extend into deep veins. In this situation - and when pulmonary embolisation occurs - if possible, the connections between superficial and deep systems (i.e. sapheno-femoral junction) should be ligated. The remaining varicose veins can treated after the acute phase. Sclerotherapy should be also used after acute phases. Intravenous catheters should be changed every 24-48 hours (depending on venous flow and clinical parameters) to prevent STPh and SVT and removed in case of events. LMWH prophylaxis and nitroglycerin patches distal to peripheral lines may reduce the incidence of SVT/STPh in patients with vein catheters. In case of SVT/STPh vein lines should be removed. In neoplastic diseases and hematological disorders, anticoagulants may be necessary. Exercise reduces pain and the possibility of DVT. Only in cases in which pain is very severe bed rest may be necessary. DVT prophylaxis should be established (LMWH) in patients with reduced mobility. Antibiotics - usually - do not have a place in SVT/STPh unless there is a documented infections. In conclusion SVT/STPh events are generally self-limiting and benign, often managed with analgesics, if limited. LMWH is effective in limiting the extension of thrombi and preventing DVT. SVT and STPh may be clues indicating important diseases. SVT is commonly associated with varicose veins while STPh (SVT in some cases) may be an indication of underlying diseases (immunological, malignancy hematological disorders). SVT is rarely associated with DVT (requiring anticoagulant treatment). Prevention of SVT (i.e. with LMWH in condition at high-risk of DVT) should be considered on the basis of clinical evaluation.