Risk of Pulmonary Embolism in Patients With Isolated Great Saphenous Vein Thrombus

Risks associated with isolated great saphenous vein (GSV) thrombosis remain controversial. The purpose of this study is to identify the risk of pulmonary embolism (PE) in patients with isolated GSV thrombosis, particularly those with thrombus within 3 cm of the sapheno-femoral junction. A retrospective chart review of color flow Doppler lower extremity venous ultrasound examinations from an academic hospital from 2011 to 2016 was conducted. Seventy-eight patients were identified as having acute thrombus in their GSV and were then further stratified based on the presence or absence of concomitant deep venous thrombosis (DVT). A control group of 49 patients who presented with leg swelling and were found to have a normal color flow Doppler examination was also identified. Patients without thrombus (n = 49), patients with isolated GSV thrombus (n = 29), and patients with GSV thrombus with concomitant DVT (n = 49) underwent full chart review to determine whether any patients developed PE. This was diagnosed specifically by computed tomography angiogram or ventilation/perfusion scan, within 60 days of initial diagnosis of lower extremity thrombus. In our analysis, there was no significant difference in the risk of PE in patients with isolated GSV thrombus compared with a control group of normal patients (3.5% vs 2.0%, P = 0.38). However, patients with GSV thrombus and concomitant DVT had a significantly increased risk of PE compared with patients with isolated GSV thrombus (26.5% vs 3.5%, P = 0.01). We found that the risk of PE in patients with isolated GSV thrombus is not significantly increased compared with a normal cohort.

Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology

PURPOSE

To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity.

METHODS

A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard.

RESULTS

One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics.

CONCLUSIONS

Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.

Superficial Vein Thrombophlebitis in a Football Athlete

A 22-year-old professional football player presented to a preparticipation physical examination with a 2-week history of left leg discomfort extending from the groin to the knee over the previous 2 weeks. He was found to have superficial vein thrombophlebitis (SVT) of the left great saphenous vein extending from the knee to within approximately 1.6 cm of the saphenofemoral junction. There is paucity in the literature regarding the management of SVT, particularly in actively training athletes. This case addresses the considerations of anticoagulation management for SVT as well as the unique challenge of managing anticoagulation therapy in an athlete that is actively training.

Management of superficial vein thrombosis

Superficial vein thrombosis (SVT) is less well studied than deep vein thrombosis (DVT), because it has been considered to be a minor, self-limiting disease that is easily diagnosed on clinical grounds and that requires only symptomatic relief. The most frequently involved sites of the superficial vein system are the lower limbs, especially the saphenous veins, mostly in relation to varicosities. Lower-limb SVT shares the same risk factors as DVT; it can propagate into the deep veins, and have a complicated course with pulmonary embolism. Clinical diagnosis may not be accurate, and ultrasonography is currently indicated for both confirmation and evaluation of SVT extension. Treatment aims are symptom relief and prevention of venous thromboembolism (VTE) in relation to the thrombotic burden. SVT of the long saphenous vein within 3 cm of the saphenofemoral junction (SFJ) is considered to be equivalent to a DVT, and thus deserving of therapeutic anticoagulation. Less severe forms of lower-limb SVT not involving the SFJ have been included in randomized clinical trials of surgery, compression hosiery, non-steroidal anti-inflammatory drugs, unfractionated heparin, and low molecular weight heparins, with inconclusive results. The largest randomized clinical trial available, on 3004 patients with lower-limb SVT not involving the SFJ, showed that fondaparinux 2.5 mg once daily for 6 weeks is more effective than placebo in reducing the risk of the composite of death from any cause and symptomatic VTE (0.9% versus 5.9%). Further studies are needed to define the optimal management strategies for SVT of the lower limbs and other sites, such as the upper limbs.

Spontaneous acute superficial vein thrombosis of the legs: do we really need to treat?

Spontaneous acute superficial vein thrombosis (SVT) of the leg is now generally recognized as an integral component of venous thromboembolic disease with potentially severe consequences. However, the relatively low grades of some current international recommendations and uncertainty regarding the cost-effectiveness of available therapies may prompt questioning of the real need to treat patients with SVT and explain the persisting heterogeneity of their management in practise. Yet several studies have consistently shown high rates of thromboembolic complications associated with SVT, whether at first presentation or during follow-up. The CALISTO trial established for the first time the clinical benefit of a well-defined anticoagulant regimen for the prevention of serious thromboembolic complications in SVT patients, and we believe that patients such as those included in this trial should receive this regimen as tested. However, several areas of uncertainty remain for categories of SVT patients not evaluated in CALISTO.

Time Course and the Recanalization Rate of Superficial Vein Thrombosis Treated With Low-Molecular-Weight Heparin

The aim of this study was to follow the thrombus progression and regression in superficial veins of lower limbs in patients with superficial vein thrombosis (SVT) treated with low-molecular-weight heparin. Patients (n = 68) with a first symptomatic SVT of the lower limbs received 2 different dosages of dalteparin. The primary outcome was a change in the diameter and length of thrombus in the affected veins. The regression of thrombus was not significantly different between the groups ( P = .19). The reduction in the length of thrombus as well as thrombus diameter was significantly greater in females. At the end of the observation period, the length of thrombus in the distal part was more reduced than in the proximal segments. It seems that the dosage of anticoagulant drug does not have a significant impact on thrombus resolution.

The disparate management of superficial venous thrombosis in primary and secondary care

OBJECTIVES

Superficial venous thrombosis is common and traditionally considered a benign condition requiring only symptomatic treatment. Recent evidence, however, advocates more aggressive management. Extensive guidance is available but actual practice is unknown. This study aimed to assess the management of superficial venous thrombosis by general practitioners (primary care physicians) and vascular surgeons.

METHODS

A 19-question validated electronic survey was created and circulated by e-mail to general practitioners and vascular surgeons in the United Kingdom. The survey evaluated presentation, investigation and treatment of superficial venous thrombosis.

RESULTS

Three hundred sixty-nine surveys were returned from 197 vascular surgeons and 172 general practitioners. Most clinicians saw less than 20 cases a year, with 40% of clinicians not performing any investigations. Venous duplex was the investigation of choice in over 55%. Treatment with anti-inflammatory drugs was widespread, but anticoagulation and compression were seldom prescribed. Follow-up and treatment duration were disparate.

DISCUSSION

The management of superficial venous thrombosis varies widely despite good levels of evidence and guidance. Investigation and treatment of superficial venous thrombosis show marked differences both between and within groups. Improvements in education are required to optimise the treatment pathway and advance patient care.

Clinical relevance of symptomatic superficial-vein thrombosis extension: lessons from the CALISTO study

Symptomatic extensions, whether or not reaching the SFJ, are common complications of SVT. Their frequency and associated risk of venous thromboembolic complications and medical resource consumption are reduced by fondaparinux.