When superficial thrombophlebitis isn’t benign
A 57 year old woman presented to the ED with left leg pain and swelling for a week. She had no past medical history, and no risk factors for DVT. On examination there was a palpable superficial cord running along the medial leg from the knee to the groin. This cord was erythematous, warm and tender – consistent with superficial thrombophlebitis. A point-of-care ultrasound was performed to examine the region of tenderness and to assess for DVT.
Ultrasound over tender cord:
This scan video shows the presence of an echogenic thrombus clearly visible in the greater saphenous vein (GSV). We know that it is a superficial vein as there is no associated artery. The vein was non-compressible.
Ultrasound of common femoral vein:
Ultrasound of sapheno-femoral junction:
The DVT scan in the proximal leg demonstrates the dilated greater saphenous vein with echogenic thrombus within its lumen. When scanning the sapheno-femoral junction, the thrombus can be seen protruding into the common femoral vein.
This case demonstrates the importance of visualizing the greater saphenous vein at the junction of the common femoral vein when looking for DVT. Approximately 6-11% of patients with isolated GSV thrombosis will progress to DVT. The risk of progression is higher in patients with proximal GSV involvement compared with distal involvement (24-40% vs 1-4%). Most of the progression will occur via the common femoral vein, while a minority will progress through small perforating veins.
The use of anticoagulants for the treatment of superficial thrombophlebitis remains controversial. A recent randomized control trial found that fondaparinux reduced the rate of DVT/PE or symptomatic recurrence from 6.3% to 0.9% for patients with GSV thrombosis. If deciding not to anticoagulate your patient, you should have them return for a repeat ultrasound to ensure that there is no progression into the deep venous system.
For more on Venous Thromobembolism, go to this podcast at EM Cases: Pulmonary Embolism Pearls & Pitfalls by Dr. Anil Chopra
Useful resources:
Chengelis et al. Progression of superficial venous thrombosis to deep vein thrombosis. J Vasc Surg. 1996 Nov;24(5):745-9. PubMed link: http://www.ncbi.nlm.nih.gov/pubmed/8918318
Ascer et al. Preliminary results of a nonoperative approach to saphenofemoral junction thrombophlebitis. J Vasc Surg. 1995 Nov;22(5):616-21. PubMed link: http://www.ncbi.nlm.nih.gov/pubmed/7494365
Decousus et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010 Sep 23;363(13):1222-32. doi: 10.1056/NEJMoa0912072. PubMed link: http://www.ncbi.nlm.nih.gov/pubmed/20860504
