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Thrombophlebitis

An acute condition characterized by inflammation and thrombus formation, thrombophlebitis may occur in deep (intermuscular or intramuscular) or superficial (subcutaneous [S.C.]) veins.

Deep-vein thrombophlebitis affects small veins, such as the soleal venous sinuses, or large veins, such as the vena cava, and the femoral, iliac, and subclavian veins. This disorder is frequently progressive, leading to pulmonary embolism, a potentially lethal complication.

Superficial thrombophlebitis is usually self-limiting and rarely leads to pulmonary embolism. Thrombophlebitis often begins with localized inflammation alone (phlebitis), but such inflammation rapidly provokes thrombus formation. Rarely, venous thrombosis develops without associated inflammation of the vein (phlebothrombosis).

Causes

Thrombophlebitis may result from infection or injury that prompts excessive clotting in the veins. It can also be caused by sitting for long periods on a plane, resting in bed for a long time, or wearing a cast. This immobility prompts blood to pool and, eventually, clot. Smoking while using birth control pills can also lead to more than the usual amount of clotting. Some cases of thrombophlebitis are a result of injury to the wall of the vein from needles or IV fluids or the spread of blood cancer.

Signs and symptoms

The following symptoms are often associated with thrombophlebitis:

• tenderness over the vein
• pain in the part of the body affected
• skin redness or inflammation (not always present)

Although deep-vein thrombophlebitis may occur asymptomatically, it may also produce severe pain, fever, chills, malaise and, possibly, swelling and cyanosis of the affected arm or leg.

Diagnosis

Some patients may display signs of inflammation and, possibly, a positive Homans' sign (pain on dorsiflexion of the foot) during physical examination; others are asymptomatic. Consequently, essential laboratory tests include the following:

• Doppler ultrasonography is used to identify reduced blood flow to a specific area and any obstruction to venous flow, particularly in iliofemoral deep-vein thrombophlebitis.
• Plethysmography shows decreased circulation distal to affected area; it's more sensitive than ultrasound in detecting deep-vein thrombophlebitis.
• Phlebography can show filling defects and diverted blood flow and usually confirms the diagnosis.

Diagnosis must rule out arterial occlusive disease, lymphangitis, cellulitis, and myositis.

Diagnosis of superficial thrombophlebitis is based on physical examination (redness and warmth over affected area, palpable vein, and pain during palpation or compression).

Treatment

The goals of treatment are to control thrombus development, prevent complications, relieve pain, and prevent recurrence of the disorder. Symptomatic measures include bed rest, with elevation of the affected arm or leg; warm, moist soaks to the affected area; and analgesics.

Deep-vein thrombophlebitis

After the acute episode of deep-vein thrombophlebitis subsides, the patient may resume activity while wearing antiembolism stockings that were applied before he got out of bed.

Treatment may also include anticoagulants (initially, heparin; later, warfarin) to prolong clotting time. Full anticoagulant dose must be discontinued during any operative period, due to the risk of hemorrhage.

After some types of surgery, especially major abdominal or pelvic operations, prophylactic doses of anticoagulants may reduce the risk of deep-vein thrombophlebitis and pulmonary embolism. For lysis of acute, extensive deep-vein thrombosis, treatment should include streptokinase.

Rarely, deep-vein thrombophlebitis may cause complete venous occlusion, which necessitates venous interruption through simple ligation to vein plication, or clipping. Embolectomy and insertion of a vena caval umbrella or filter may also be done.

Superficial thrombophlebitis

Therapy for severe superficial thrombophlebitis includes an antiinflammatory drug such as indomethacin, antiembolism stockings, warm soaks, and elevation of the leg.

Prevention

Routine changing of intravenous (IV) lines helps to prevent phlebitis related to IV lines. See the specific disorders associated with thrombophlebitis for other preventive measures.