Thrombus of Distal Saphenous Vein - anticoagulate, refer, other?

[Guest guest]

Have 30ish Hispanic female with history of varicose veins.

Comes to me for varicose vein consult, but found to have large tortuous saphenous varicosity with superficial cord in vein of the calf and tenderness along the distal medial thigh.

Sent for U/S and found to have distal saphenous thrombus, but no DVT.

 

What would you do?

 

Anticoagulate?

 

Send for referral to specialist in phlebology?

 

Below suggests -- considered for anticoagulation or ligation of the saphenous vein

 

Thoughts?

 

Been an interesting day.

 

Locke, MD

 

http://emedicine.medscape.com/article/463256-overview

 

Patients who present with thrombosis of the long or short saphenous veins should be considered for anticoagulation or ligation of the saphenous vein. A high incidence (6-44%) of concurrence or progression to deep venous thrombosis has been reported.

Ascher et al reported that 65.6% of patients who present with long saphenous vein thrombosis were found to have associated deep vein thrombosis.11

Optimal treatment of saphenous thrombosis remains controversial. As noted by Wichers et al in a recent systematic review, a lack of randomized trials prevents evidence-based recommendations in this area.12

In a small randomized trial of 60 patients with long saphenous thrombosis, Lozano et al compared treatment using low molecular weight heparin (LMWH) with surgical saphenous ligation.13 Patients in the LMWH group experienced no episodes of deep vein thrombosis or pulmonary embolism but had a 10% incidence of recurrent superficial vein thrombosis. Patients treated surgically were found to have 2 pulmonary emboli (6.7%) and 1 episode of recurrent superficial vein thrombosis (3.3%).

In a larger randomized trial (Stenox study), 436 patients with superficial vein thrombosis were randomized to placebo treatment compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or 2 doses of LMWH. All patients wore compression stockings. No statistical difference in the incidence of deep vein thrombosis or pulmonary embolism between the groups was found. The placebo group had a higher incidence of recurrent superficial vein thrombosis than the other 3 groups. Interestingly, the group treated with NSAIDs was no different than those treated with LMWH.

Wichers et al conclude, after systematic review of the literature, that LMWH or NSAID therapy appears to reduce the incidence of superficial vein thrombosis extension or recurrence.12 Larger trials are likely required to demonstrate differences in the incidence of deep vein thrombosis. Treating patients with some form of low- or intermediate-dose anticoagulation appears reasonable at this time, followed by repeat duplex ultrasound to look for progression at intervals for a few weeks to a month. In patients with stable nonprogressing thrombus, anticoagulation therapy can probably be discontinued in the absence of other risk factors.

Patients with contraindications to anticoagulation or those receiving adequate anticoagulation treatment who have progression of thrombosis should be considered for saphenous ligation at the junction with the deep venous system.

 

 

http://findarticles.com/p/articles/mi_m0689/is_7_53/ai_n6130761/

What is the best therapy for superficial thrombophlebitis?

Journal of Family Practice, July, 2004 by L. Greenwald

 

* EVIDENCE-BASED ANSWER

For proximal saphenous vein thrombosis, anticoagulation is more effective than venous ligation (with or without stripping) in preventing deep venous thrombosis (DVT) and pulmonary embolus (PE) (strength of recommendation [sOR]: C, qualitative systematic review of primarily case series).

For patients with superficial venous thrombophlebitis (SVTP) distal to the saphenous vein of the thigh, tenoxicam (a nonsteroidal anti-inflammatory agent [NSAID]) and low-molecular-weight heparin are similarly effective for reducing extension and subsequent DVT when administered along with compression therapy (SOR: B, 1 randomized controlled trial). Oral or topical NSAIDs, topical heparin, and topical nitroglycerin all alleviate symptoms and speed resolution of SVTP caused by infusion catheters (SOR: B, smaller, occasionally conflicting randomized trials).

* EVIDENCE SUMMARY

Superficial thrombophlebitis refers to erythema, pain, induration, and other findings of inflammation in superficial veins, usually due to infection or thrombosis. Typically, SVTP is localized problem, but some lower-extremity SVTP is associated with increased risk of DVT and PE, particularly the long saphenous vein. This review will not address thrombosis in the superficial femoral vein, a portion of the deep venous system, which requires full DVT therapy. (1)

Since saphenous vein thrombosis above the knee is associated with DVT and PE, 1 systematic review looked at papers comparing anticoagulation (IV heparin followed by 6 weeks to 6 months of warfarin) with surgical ligation of the saphenous vein (either alone or combined with vein stripping or with vein stripping and perforator ligation). (1) The review included primarily case series with widely varying protocols. According to the authors, the data " suggests that medical management with anticoagulants is somewhat superior to surgery for preventing DVT and PE. However, the fewest extensions of SVTP occurred when vein ligation was combined with stripping of the thrombosed vein and interruption of perforators.

In a more recent trial, patients randomized to subcutaneous heparin at 12,500 units twice daily for a week followed by 10,000 units twice daily had fewer vascular complications of proximal saphenous vein thrombosis than those receiving heparin at 5000 units twice daily (6/30 in the low-dose group and 1/30 in the high-dose group; P<.05; number needed to treat [NNT]=6). (2) There were no bleeding complications in either group.

One large double-blind randomized controlled trial compared tenoxicam (an NSAID available in Canada, similar to piroxicam), enoxaparin (Lovenox), and placebo for 8 to 12 days in 427 patients with SVTP of the leg measuring 5 cm or more. (3) Patients were also treated with compression hose. Patients who required immediate anticoagulation or venous ligation were excluded. Within 3 months, 35% of patients taking placebo developed an extension or recurrence of their SVTP or a DVT, compared with 16% to 17% of treated patients (NNT=6). There was no significant difference in outcome between subcutaneous enoxaparin at fixed (40 mg/d) or adjusted doses (1.5 mg/kg), or 20 mg/d oral tenoxicam. In a small randomized trial (n=40), intramuscular defibrotide provided better symptom resolution than low-dose heparin for patients with uncomplicated SVTP of the leg. (4)

For infusion-related SVTP, a randomized controlled trial of 120 patients found both oral and topical diclofenac effective in reducing symptoms (NNT=3), although oral diclofenac had significantly more gastrointestinal side effects (number needed to harm=3 for dyspepsia). (5) Two double-blind trials of topical heparin showed it to be superior to placebo in reducing symptoms and speeding healing. (6,7)

In the larger study (n=126), 44% of patients treated with 1000 IU/g heparin gel 3 times a day were symptom-free at 1 week, compared with 26% on placebo (NNT=6). (7) A randomized trial of infusion-related SVTP (n=100) found that 2% nitroglycerin gel eliminated pain in 50 hours vs 72 hours with topical heparin (P<.05). (8) A smaller, underpowered double-blind trial of topical heparin, piroxicam gel, and placebo (22 to 24 patients in each treatment arm) failed to find efficacy with either therapy. (9)

* RECOMMENDATION FROM OTHERS

For SVTP of the leg that does not include the proximal saphenous vein, Up To Date recommends compression and oral NSAIDs, noting that NSAIDs are inexpensive, help with symptom control, and appear comparable to low-molecular-weight heparin in limiting complications. (10)

REFERENCES

(1.) Sullivan V, Denk PM, Sonnad SS, Eagleton MJ, Wakefield TW. Ligation versus anticoagulation: treatment of above-knee superficial thrombophlebitis not involving the deep venous system. J Am Coll Surg 2001; 193:556-562.

(2.) Marchiori A, Verlato F, Sabbion P, et al. High versus low doses of unfractionated heparin for the treatment of superficial thrombophlebitis of the leg. A prospective, controlled, randomized study. Haematologica 2002; 87:523-527.

[Guest guest]

-

Recent study ls Int Med Feb 2010.

800+ patients, 10% risk complication DVT/PE.

I'd discuss with pt, but would lean towards anticoag.

At a minimum, I'd re-ultrasound in a week (r/o pregression) if elected

to not anticoagulate but without contraindications.

(Don't know about the data, but could consider a removable IVC

filter...).

Reference below, can email article to you off-list if interested.

Steve Hersch

Ashland, OR

Superficial Venous

Thrombosis and Venous Thromboembolism: A Large, Prospective Epidemiologic Study

Ann

Intern Med February 16, 2010 152:218-224; doi:10.1059/0003-4819-152-4-201002160-00006

Decousus

and colleagues assessed the prevalence and incidence of venous

thromboembolism in 844 patients with superficial venous thrombosis who

were evaluated by vein specialists in France. About 25% of patients had

deep venous thrombosis at presentation, and about 10% developed

thromboembolic complications over the next 3 months. Superficial venous

thrombosis may not be as benign as is commonly believed and may be a

marker for more clinically significant thromboembolic risk.

Locke wrote:

Have 30ish Hispanic female with history of varicose veins.

Comes to me for varicose vein consult, but found to have large

tortuous saphenous varicosity with superficial cord in vein of the calf

and tenderness along the distal medial thigh.

Sent for U/S and found to have distal saphenous thrombus, but no

DVT.

What would you do?

Anticoagulate?

Send for referral to specialist in phlebology?

Below suggests -- considered for

anticoagulation or ligation of the saphenous vein

Thoughts?

Been an interesting day.

Locke, MD

http://emedicine.medscape.com/article/463256-overview

Patients who present with thrombosis of the long or short

saphenous veins should be considered for

anticoagulation or ligation of the saphenous vein.

A high incidence (6-44%) of concurrence or progression to deep venous

thrombosis has been reported.

Ascher et al reported that 65.6% of patients who present with long

saphenous vein thrombosis were found to have associated deep vein

thrombosis.11

Optimal treatment of saphenous thrombosis remains

controversial.

As noted by Wichers et al in a recent systematic review, a lack of

randomized trials prevents evidence-based recommendations in this area.12

In a small randomized trial of 60 patients with long

saphenous thrombosis, Lozano et al compared treatment using low

molecular weight heparin (LMWH) with surgical saphenous ligation.13 Patients in the LMWH group

experienced no episodes of deep vein thrombosis or pulmonary embolism

but had a 10% incidence of recurrent superficial vein thrombosis.

Patients treated surgically were found to have 2 pulmonary emboli

(6.7%) and 1 episode of recurrent superficial vein thrombosis (3.3%).

In a larger randomized trial (Stenox study), 436 patients

with superficial vein thrombosis were randomized to placebo treatment

compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or 2 doses

of LMWH. All patients wore compression stockings. No statistical

difference in the incidence of deep vein thrombosis or pulmonary

embolism between the groups was found. The placebo group had a higher

incidence of recurrent superficial vein thrombosis than the other 3

groups. Interestingly, the group treated with NSAIDs was no different

than those treated with LMWH.

Wichers et al conclude, after systematic review of the

literature, that LMWH or NSAID therapy appears to reduce the incidence

of superficial vein thrombosis extension or recurrence.12 Larger trials are likely required

to demonstrate differences in the incidence of deep vein thrombosis.

Treating patients with some form of low- or intermediate-dose

anticoagulation appears reasonable at this time, followed by repeat

duplex ultrasound to look for progression at intervals for a few weeks

to a month. In patients with stable nonprogressing thrombus,

anticoagulation therapy can probably be discontinued in the absence of

other risk factors.

Patients with contraindications to anticoagulation or those

receiving adequate anticoagulation treatment who have progression of

thrombosis should be considered for saphenous ligation at the junction

with the deep venous system.

http://findarticles.com/p/articles/mi_m0689/is_7_53/ai_n6130761/

What is the best therapy for superficial thrombophlebitis?

Journal of Family

Practice, July, 2004

by

L. Greenwald

* EVIDENCE-BASED ANSWER

For proximal saphenous vein thrombosis, anticoagulation is more

effective than venous ligation (with or without stripping) in

preventing deep venous thrombosis (DVT) and pulmonary embolus (PE)

(strength of recommendation [sOR]: C, qualitative systematic review of

primarily case series).

For patients with superficial venous thrombophlebitis (SVTP)

distal to the saphenous vein of the thigh, tenoxicam (a nonsteroidal

anti-inflammatory agent [NSAID]) and low-molecular-weight heparin

are similarly effective for reducing extension and subsequent DVT when

administered along with compression therapy (SOR: B, 1 randomized

controlled trial). Oral or topical NSAIDs, topical heparin, and topical

nitroglycerin all alleviate symptoms and speed resolution of SVTP

caused by infusion catheters (SOR: B, smaller, occasionally conflicting

randomized trials).

* EVIDENCE SUMMARY

Superficial thrombophlebitis refers to erythema, pain, induration,

and other findings of inflammation in superficial veins, usually due to

infection or thrombosis. Typically, SVTP is localized problem, but some

lower-extremity SVTP is associated with increased risk of DVT and PE,

particularly the long saphenous vein. This review will not address

thrombosis in the superficial femoral vein, a portion of the deep

venous system, which requires full DVT therapy. (1)

Since saphenous vein thrombosis above the knee is associated with

DVT and PE, 1 systematic review looked at papers comparing

anticoagulation (IV heparin followed by 6 weeks to 6 months of

warfarin) with surgical ligation of the saphenous vein (either alone or

combined with vein stripping or with vein stripping and perforator

ligation). (1) The review included primarily case series with widely

varying protocols. According to the authors, the data "suggests that

medical management with anticoagulants is somewhat superior to surgery

for preventing DVT and PE. However, the fewest extensions of SVTP

occurred when vein ligation was combined with stripping of the

thrombosed vein and interruption of perforators.

In a more recent trial, patients randomized to subcutaneous

heparin at 12,500 units twice daily for a week followed by 10,000 units

twice daily had fewer vascular complications of proximal saphenous vein

thrombosis than those receiving heparin at 5000 units twice daily (6/30

in the low-dose group and 1/30 in the high-dose group; P<.05; number

needed to treat [NNT]=6). (2) There were no bleeding complications in

either group.

One large double-blind randomized controlled trial compared

tenoxicam (an NSAID available in Canada, similar to piroxicam),

enoxaparin (Lovenox), and placebo for 8 to 12 days in 427 patients with

SVTP of the leg measuring 5 cm or more. (3) Patients were also treated

with compression hose. Patients who required immediate anticoagulation

or venous ligation were excluded. Within 3 months, 35% of patients

taking placebo developed an extension or recurrence of their SVTP or a

DVT, compared with 16% to 17% of treated patients (NNT=6). There was no

significant difference in outcome between subcutaneous enoxaparin at

fixed (40 mg/d) or adjusted doses (1.5 mg/kg), or 20 mg/d oral

tenoxicam. In a small randomized trial (n=40), intramuscular

defibrotide provided better symptom resolution than low-dose heparin

for patients with uncomplicated SVTP of the leg. (4)

For infusion-related SVTP, a randomized controlled trial of 120

patients found both oral and topical diclofenac effective in reducing

symptoms (NNT=3), although oral diclofenac had significantly more

gastrointestinal side effects (number needed to harm=3 for dyspepsia).

(5) Two double-blind trials of topical heparin showed it to be superior

to placebo in reducing symptoms and speeding healing. (6,7)

In the larger study (n=126), 44% of patients treated with 1000

IU/g heparin gel 3 times a day were symptom-free at 1 week, compared

with 26% on placebo (NNT=6). (7) A randomized trial of infusion-related

SVTP (n=100) found that 2% nitroglycerin gel eliminated pain in 50

hours vs 72 hours with topical heparin (P<.05). (8) A smaller,

underpowered double-blind trial of topical heparin, piroxicam gel, and

placebo (22 to 24 patients in each treatment arm) failed to find

efficacy with either therapy. (9)

* RECOMMENDATION FROM OTHERS

For SVTP of the leg that does not include the proximal saphenous

vein, Up To Date recommends compression and oral NSAIDs, noting that

NSAIDs are inexpensive, help with symptom control, and appear

comparable to low-molecular-weight heparin in limiting

complications. (10)

REFERENCES

(1.) Sullivan V, Denk PM, Sonnad SS, Eagleton MJ, Wakefield TW.

Ligation versus anticoagulation: treatment of above-knee superficial

thrombophlebitis not involving the deep venous system. J Am Coll Surg

2001; 193:556-562.

(2.) Marchiori A, Verlato F, Sabbion P, et al. High versus low

doses of unfractionated heparin for the treatment of superficial

thrombophlebitis of the leg. A prospective, controlled, randomized

study. Haematologica 2002; 87:523-527.