[Management of superficialis thrombophlebitis. Guidelines of the Angiologiy Section of the Slovak Medical Chamber (2013)]

The aim of Guidelines of the Angiology Section of the Slovak Medical Chamber (AS SMC) is to address a last european guidelines for the management of thrombophlebitis superficialis, as well as results in evidence based  medicine (EBM) in order to assess their contribution to our expanding knowledge on rational management of thrombophlebitis superficialis.

DISCUSSION

Superficial thrombophlebitis is a common disease, usually considered to be benign. However, the practice of systemic duplex ultrasonography has revealed a large number of cases of deep vein thrombosis concomitant with superficial thrombophlebitis. Assessment of clinical probability of deep vein thrombosis and venous tromboembolism and systematic duplex ultrasound investigation has been proposed in the initial management of superficial thrombophlebitis, to detect the presence of any underlying deep vein thrombosis. In contrast with extensive information on the management of deep vein thrombosis, there is little knowledge about the most appropriate treatment of the superficial thrombophlebitis.

CONCLUSION

The treatment of superficial thrombophlebitis should improve local symptoms while preventing the development of complications such as venous thromboembolism. The most effective therapeutic approach to superficial thrombophlebitis seems to be represented by fondaparinux (a synthetic selective indirect inhibitor of factor Xa) which have been shown to prevent VTE events and the extension and/ or recurrence of superficial thrombophlebitis.

[Ascending thrombophlebitis of the greater saphenous vein: proposal of a new morphological classification]

Superficial thrombophlebitis has been considered a self-limiting, benign disease without any significant incidence of morbidity or mortality. Thrombosis of the saphenous vein close to the deep venous system is a potentially dangerous clinical situation that may progress to deep venous thrombosis and pulmonary embolism. We retrospectively analysed 32 patients with ascending thrombophlebitis of the proximal greater saphenous vein who underwent emergency surgical ligation of the saphenofemoral junction. In 3 patients (9%) a femoral thrombectomy was performed because we observed an extension of the thrombus to the femoral vein intraoperatively. The postoperative morbidity and mortality rates were 0%, while the incidence of postoperative pulmonary embolism was 3%. In our opinion, emergency surgical ligation of the saphenofemoral junction is a valid alternative to medical treatment for thrombophlebitis of the proximal greater saphenous vein. At the moment no randomised comparison of the efficacy of different treatments tested in a large series is available. According to our experience and on the basis of the anatomical and haemodynamic studies conducted by Bisacci and Genovese, we have identified 2 different types of thrombophlebitis of the proximal greater saphenous vein, which require different treatments. In type 1, the thrombus does not reach the pre-ostial valve; simple ligation of the saphenofemoral junction after its opening is necessary. In type 2, the thrombus goes beyond the pre-ostial valve; thrombectomy, saphenofemoral disconnection and postoperative anticoagulation are mandatory.

[Stage-adapted therapy concept in ascending thrombophlebitis]

Varicophlebitis is the most frequent and important acute complication of a varicosed long and/or short saphenous vein. In view of the controversial discussion about the either conservative or surgical treatment, a clinically relevant classification of this syndrome appears useful: Stage I includes varicophlebitis without involvement of the respective junctional valve--in the groin or at the knee--and deep veins. While in Stage II the proximal part of the thrombus has reached the respective junctional valves of the long or short sapheneous vein, in Stage III it has entered the deep veins by means of these valves. In Stage IV the thrombus migrates via insufficient perforating veins into the deep system. Stages I and IV should be treated conservatively first, removal of the varicous veins should be performed after regression of the acute symptoms. Stages II and III should be considered an indication for urgent surgery. The surgical strategy consists of crossectomy, resection of the saphenous vein without stripping, radical excision of all varicous veins and ligature of insufficient perforating veins. In stage III the thrombectomy of the deep veins using the Fogarty-procedure must be carried out before any other measures are taken. In 1996 a total number of 40 limbs with ascending varicophlebitis (stage I = 16, stage II = 19, stage III = 5) was observed. 10 extremities (stage I = 2, stage II = 5, stage III = 3) underwent surgical treatment. 1 patient developed a deep infection of the groin, the average stay in hospital was 9 days.

A volumetric index for the quantification of deep venous thrombosis

PURPOSE

The evaluation of treatment strategies for deep venous thrombosis (DVT) is assessed through the use of a reliable method of quantifying the extent of the thrombotic process. Previous indices of thrombus burden have suffered from various limitations, including lack of clinical relevance, poor correlation with actual thrombus mass, and failure to include important venous segments in the methodology. The use of a novel scheme of quantifying venous thrombus was evaluated as an alternative method that would avoid some of the drawbacks of existing indices.

METHODS

The volumes of 14 venous segments (infrarenal inferior vena cava, common iliac, hypogastric, external iliac, common femoral, profunda, superficial femoral, and popliteal and six tibial veins) were calculated from computed tomography (pelvic vein diameter), duplex ultrasound scan (infrainguinal vein diameter), and contrast venography (length of all segments) measurements. A venous volumetric index (VVI) was assigned with the normalization of the values to the volume of a single calf vein. The VVI was validated with the assessment of the ability to discriminate between asymptomatic and symptomatic DVT and between those DVT that were associated with pulmonary emboli and those that were not.

RESULTS

With the imaging data, the VVI ranged from 1 for a single calf vein thrombus to 26 for the infrarenal inferior vena cava. Each VVI unit represented 2.3 mL of thrombus, with a maximum possible score of 63 representing a thrombus burden of 145 mL for a single extremity, including the infrarenal inferior vena cava. In 885 patients with DVT, the VVI ranged from 1 to 56, averaging 3.9 +/- 0.2 in patients who were asymptomatic and 8.7 +/- 0.3 in patients who were symptomatic (P <.001). The VVI was similar in the patients with pulmonary emboli as compared with those without (9.6 +/- 1.2 vs 7.7 +/- 0.2, respectively). In comparison with the three existing methods of quantifying venous thrombus burden, the receiver operating characteristic curve analysis results suggested that the VVI and the Venous Registry index were better than the other two indices in the discrimination of patients with symptomatic and asymptomatic DVT (P <.001).

CONCLUSION

A novel index of venous thrombus burden, on the basis of actual venous volume measurements, was more accurate than present indices in the differentiation between clinical categories of patients with DVT. As such, it offers an acceptable alternative to current scoring systems.

[Ascending varicose vein phlebitis--classification and therapy]

Ascending varicophlebitis can cause pulmonary embolism by entering the deep venous system. Classification into four stages permits a differentiated therapeutic strategy: if the thrombus reaches or enters the deep venous system, immediate surgery consisting of crossectomy, resection of the saphenous vein, radical excision of all varicosed veins and ligature of insufficient perforating veins are indicated.

Peripheral intravenous lines: time in situ related to complications

The purpose of this study is to examine the relationship between time in situ and the frequency of thrombophlebitis. Nurses' care and handling when using a peripheral intravenous (p.i.v.) line was also studied. The methods used were observation, interview, and document analysis after intervention, with respect to cannula time in situ. The study included 120 patients divided in two groups: (1) experimental, time in situ less than or equal to 24 hours, and (2) control, using current/daily routines from the wards. The frequency of thrombophlebitis after a p.i.v. was inserted was significantly higher and showed more troublesome and prolonged picture complications in the control group than in the experimental group. Care and handling suffered with increased number of days in situ. The nurses' documentation of inserted or removed cannula was incomplete in most cases, and notices about the insertion area were nearly nonexistent. It was determined that a short time in situ--when using a p.i.v.--is an important factor in preventing complications.

Identification of the same factor V gene mutation in 47 out of 50 thrombosis-prone families with inherited resistance to activated protein C

Resistance to activated protein C (APC) is the most prevalent inherited cause of venous thrombosis. The APC resistance phenotype is associated with a single point mutation in the factor V gene, changing Arg506 in the APC cleavage site to a Gln. We have investigated 50 Swedish families with inherited APC resistance for this mutation and found it to be present in 47 of them. Perfect cosegregation between a low APC ratio and the presence of mutation was seen in 40 families. In seven families, the co-segregation was not perfect as 12 out of 57 APC-resistant family members were found to lack the mutation. Moreover, in three families with APC resistance, the factor V gene mutation was not found, suggesting another still unidentified cause of inherited APC resistance. Of 308 investigated families members, 146 were normal, 144 heterozygotes, and 18 homozygotes for the factor V gene mutation and there were significant differences in thrombosis-free survival curves between these groups. By age 33 yr, 8% of normals, 20% of heterozygotes, and 40% of homozygotes had had manifestation of venous thrombosis.

Noninvasive blood flow tests in vascular disease

Noninvasive testing is now routine for assessing vascular conditions. Many noninvasive tests are available for obtaining physiologic and anatomic information that is both precise and reproducible. This paper discusses noninvasive testing with plethysmography, Doppler ultrasonography, and duplex scanning for carotid artery occlusive disease, deep venous thrombosis, and peripheral arterial occlusive disease.

[Blue phlebitis with exo- and endo-caval filters: 5 case reports]

5 cases of phlegmatia caerula dolens have been observed after the fixation of a cava blocking. You will find below the characteristics of the case reports: Mean age of patients: 69.2, from 55 to 83. Early phlegmatiae caeruleae dolens: 2 cases; late phlegmatiae: 3 cases (3 and 4 years after the cava ligature). Clinical context: advanced age; general state alteration 1 case; artery predisposition: 2 cases; heparin thrombopenia: 1 case. Responsible material: ombrelle de Mobin Uddin: 3 cases; Adams-De Weese's Clip: 2 cases. Current filters are probably less thrombogenous. Nevertheless, these case reports make us aware of the fact that in case of predisposition and/or in case of precary hemodynamic conditions, any factor likely to generate or worsen a venous stasis can originate (immediately or later) a significant thrombosis and, particularly in a few conditions, a phlegmatia caerulea dolens. Consequently, partial cava blocking indications must be seriously taken into consideration and saved for cases in which embolic risk is patent.

[Phlebothrombosis or thrombophlebitis? That is the question!]

We have studied retrospectively 29 patients with a red blood cells venography preceded by a flow study allowing the evaluation of the microcirculation of the limbs. Fifteen of these patients had a normal flow study and fourteen had an increased one. We have correlated these 2 groups of patients with their incidence of pulmonary embolism. With the normal flow study, there was an incidence of 12/15 (80%) of pulmonary embolism and with the increased flow, it was 6/14 (43%). We conclude that the flow study preceding the red blood cells venography can identify a subgroup of patients at high risk of pulmonary embolism.

Venous ultrasonography

Compression ultrasonography supplemented by pulsed and color Doppler imaging is the diagnostic modality of choice for evaluating lower extremity deep vein thrombosis in symptomatic and asymptomatic high-risk patients. Furthermore, this technique frequently can characterize the clot as occlusive or nonocclusive or acute or chronic and can define the extent of disease. In patients without thrombosis, this modality can suggest an alternative diagnosis in 12% of patients.

Changing concepts of deep venous thrombosis of the upper extremity--report of a series and review of the literature

Deep venous thrombosis (DVT) of the upper extremity has recently been recognized as being more common than previously reported (probably because of the increasingly frequent use of subclavian venous access). A retrospective review of patients in whom subclavian or axillary DVT had developed in the past 6 years (1980 to 1986) was conducted at the Akron General Medical Center. The major cause identified was related to subclavian venous catheterization, which accounted for 39% of all instances of subclavian and axillary DVT. Our results are correlated with a review of the literature. In our review of studies in which subclavian venous catheterizations were prospectively examined with use of objective means of diagnosis, we found that 28% of all subclavian catheterizations had venous thrombosis develop, often subclinically. This is not an innocuous disease, as suggested in the past; in our series 12% of upper-extremity DVT had pulmonary embolization (PE). In reviewing the recent literature, we found an average 12.4% incidence of PE, which often occurs during anticoagulation treatment. Diagnostic modalities are discussed and treatment regimens are reviewed along with an extensive literature review.

Reporting standards in venous disease. Prepared by the Subcommittee on Reporting Standards in Venous Disease, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery

This report comprises suggested reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism. Attempts have been made to set forth numeric grading schemes for disease severity, risk factors, and outcome criteria. Some of the recommendations had to be arbitrary of necessity, but they were judged the most generally acceptable by members of the committee. They are offered not as binding rules but as guidelines whose observance will serve the clarity and precision of communication.

Assessment of chronic venous insufficiency using dynamic venous pressure studies

In this study, 207 consecutive limbs with chronic venous insufficiency were evaluated with dynamic venous pressure studies and they were correlated with the clinical presentation and results of definitive radiologic studies with ascending and descending venography. Multiple methods of performing the pressure studies, by active exercise, passive manual compression, and tourniquet application at the calf and ankle, proved useful in distinguishing the severity and location of venous disease. The limits of confidence that can be ascribed to the dynamic venous pressure studies were also determined.

Surgical implications of ovarian vein thrombosis

Ovarian vein thrombosis, with rare exceptions, is a puerperal process that often mimicks appendicitis but may be recognized only in retrospect as a source of continued pulmonary embolization. Ovarian vein thrombosis may also accompany septic pelvic thrombophlebitis and constitute a life-threatening problem. Ovarian vein thrombosis probably exists in a subclinical form as well, and the relative infrequency of reports of this entity attest to the lack of clinical recognition rather than to its clinical rarity. Most instances of ovarian vein thrombosis will respond to antibiotics, anticoagulation, hydration and bed rest but, when septic in etiology, interruption of the vena cava and ovarian veins may be required. Acute appendicitis, the most frequent misdiagnosis, often leads to exploration, and careful resection of the affected vein in such patients generally results in cure.