Treating thrombophlebitis

Thrombophlebitis is a condition whereby veins, normally in the lower half of the body become inflamed due to the presence of a blood clot or clots. There are three known types; superficial thrombophlebitis, deep vein thrombosis and migratory thrombophlebitis, each requiring different treatment. Veins can either feel hot, bumpy and tender to touch (in the case of superficial thrombophlebitis) or symptoms might be less visible (with DVT) and may feel like a dull ache or muscle pain.

Professor Mark Whiteley is here to tell us what treatment is required for thrombophlebitis and what symptoms we should be seeking emergency treatment for.

Generally, treatment for thrombophlebitis involves anti-inflammatory medication and painkillers, support garments if needed, and if the condition is in leg veins, checking that the thrombus/clot does not extend close to deep veins. A duplex ultrasound can see the condition of the veins. If thrombophlebitis is near deep veins, 1% of cases will send a clot to the lungs, so anticoagulation should be started as soon as possible in these cases.

Long term treatment is to remove the cause of thrombophlebitis. In the legs, this is usually varicose veins, which can be treated successfully with endovenous surgery. Now let’s take a closer look at how each type of thrombophlebitis is treated.

Superficial thrombophlebitis

The immediate treatment for superficial thrombophlebitis is symptom relief. Superficial thrombophlebitis is inflammation of a vein due to the formation of a thrombus/clot within the vein. There is no infection, so antibiotics are not needed. Nonsteroidal anti-inflammatories are useful to both relieve pain and to help settle inflammation. A cold compress can also help. Support stockings can help to relieve symptoms if the affected vein is in the leg.

If there is any chance that thrombophlebitis might be near the saphenofemoral junction or saphenopopliteal junction (groin area), the patient should be urgently referred for a venous duplex ultrasound scan. If the clot extends to within 5-7cm of the junction with the deep vein, then full anticoagulation is recommended.

Once the acute episode of thrombophlebitis has settled, it is then necessary to try and correct the underlying cause to prevent the same thing happening again in the future. The commonest cause of superficial thrombophlebitis is varicose veins. If this is the case, the patient should undergo venous duplex ultrasonography followed by endovenous treatment of the varicose veins. This should prevent recurrent superficial thrombophlebitis.

Deep vein thrombosis

Deep vein thrombosis usually occurs in the lower limbs, although it is possible to get this in the upper limbs. Definitive diagnosis is made with venous duplex ultrasonography. Some units use a blood test to indicate inflammation such as D-dimer. If this is positive, it shows that there is inflammation but it is non-specific as to the cause.

Generally, if deep vein thrombosis is in the pelvic veins or in the major deep veins in the leg above the knee, anticoagulation is the norm. This does not take away the clot that has already formed but does prevent further clots from forming. By preventing clots from spreading, the body is able to get rid of the original clot. There have been studies performed to see if removal of the clot by either physically taking it out or dissolving it chemically (thrombolysis) is helpful. However, these are relatively inconclusive, so unless there is a threat to the limb or life, anticoagulation is still the mainstay of treatment.

If deep vein thrombosis is below the knee, many doctors won’t use anticoagulation solely. They may prescribe aspirin or clopidogrel, recommend to keep the limb mobile and to wear support stockings. Usually, the patient will be scanned again to make sure the clot has not spread within 24 to 48 hours.

The treatment protocols of deep vein thrombosis are actively changing as more studies are being performed. In addition, patients who are at a higher risk either due to immobility, obesity, other medical conditions including cancer, family history of thrombosis and recent major surgery may well be treated differently or more aggressively than the above.

Migratory thrombophlebitis (thrombophlebitis migrans)

Migratory thrombophlebitis doesn't actually occur. The clot itself does not migrate from one limb to another. However, there is a general systemic problem causing thrombosis within the blood vessels. Therefore, thrombophlebitis appears in one vessel followed by thrombophlebitis in another vessel, often in another limb. Hence it appears to "migrate".

This is often linked with malignancy such as pancreatic or lung cancer. As such, immediate symptomatic relief can be given in the form of painkillers and anti-inflammatories and intravenous heparin or other anticoagulation can be started. However, this should also be started at the same time as looking for the underlying malignancy.

What symptoms would require emergency treatment?

Superficial thrombophlebitis that is in the upper or inner mid-thigh, or in the mid-line of the calf should be referred urgently for a venous duplex ultrasound scan and anticoagulation to prevent a pulmonary embolism (clot travelling to the lung).

Deep vein thrombosis; if the whole leg swells, gets painful and goes blue (phlegmasia cerulea dolens) or white (phlegmasia alba dolens) the patient should be sent to accident and emergency. These conditions are due to very extensive DVT that can be life or limb-threatening if not treated straight away.

If you would like to talk about thrombophlebitis or you suffer from varicose veins, it’s best to book an appointment with a vascular surgeon such as Professor Whiteley