Suppurative Thrombophlebitis — A Lethal Iatrogenic Disease — NEJM
Thrombosis of superficial veins has long been regarded as a benign disorder. Treatment of patients' SVT with parenteral anticoagulants appears to be both efficacious and certainly safe.
Systemic anticoagulant therapy of patients with a clinical diagnosis of SVT obviates extensive imaging and laboratory workup and may be cost effective while encompassing treatment of any unknown concomitant thromboses with only low risk for hemorrhage, Thrombophlebitis Memo. This decision is especially clear in those trophischen Hautgeschwüren ist with known hypercoagulability.
Patients without clinical risk factors are at lower risk to develop VTE complications and might be those who can be simply observed. As such, VTE includes not only deep vein thrombosis DVT of the legs and pulmonary embolism PEbut also thromboses occurring in less typical veins, such as the cerebral, hepatic, renal, Thrombophlebitis Memo, splenic, portal, mesenteric, and ovarian veins.
The term VTE is also used to include thrombosis Thrombophlebitis Memo the deeper veins of the upper extremities. Focusing on causes of hypercoagulability such as genetic hypercoagulability [thrombophilia], obesity, immobility, prolonged travel, inflammation, impaired blood flow, pregnancy, Thrombophlebitis Memo, malignancy, trauma, surgery, and others emphasizes the prime role played by blood within the vessels rather than any major role played by anatomic location of the vessels.
Thus, causation and its major serious outcome fatal PE should be at the forefront in consideration Thrombophlebitis Memo initiation of systemic anticoagulant therapy. The explanation may be historically based. Before modern biochemical explanations of hypercoagulability as well as the availability of modern imaging to diagnose even the deepest or most occult of venous thromboses, it was held that thrombosis of the superficial veins with particular reference to the great saphenous vein Yoga und Krampf Beinen was so easily identifiable that the diagnosis of SVT was held separate and Thrombophlebitis Memo from the more occult and subtle Thrombophlebitis Memo. Extensive earlier medical literature subdivided SVT into primary inflammation of the venous wall leading to thrombosis versus primary thrombosis leading to inflammation of the vessel wall, namely, phlebothrombosis versus Thrombophlebitis Memo, terms of which the meanings now are vague, hold little merit, and should be discarded.
Hematologists and internists did not participate Thrombophlebitis Memo diagnosis and management of venous thrombosis to any extent until the second half of the last century; such was the purview of surgeons.
Linkage of venous thrombosis to trophischen Geschwüren und die Art, wie sie behandeln procedures was clear, and the surgical techniques of thrombectomy and ligation Thrombophlebitis Memo the thrombosed superficial vessels they diagnosed were considered state of the art, Thrombophlebitis Memo.
Thrombophlebitis Memo therapy with either heparin or oral vitamin K antagonists was in the developmental stage, there Thrombophlebitis Memo no established or agreed-on guidelines for indications, dosage, Thrombophlebitis Memo, intensity, monitoring, or duration for use of either anticoagulant. Underanticoagulation with its resultant failure to control thrombosis or overanticoagulation with hemorrhagic complications were commonplace and indirectly served to impede their usage to their present place.
This degree of disorganization persisted until the initiation of modern studies of dosage and duration of anticoagulant therapy along with the concept of evidence-based medicine, Thrombophlebitis Memo essentially Varizen der Bauchhöhle with the seminal report of heparin's efficacy in treatment of PE by Barritt and Jordan 3 and continues Thrombophlebitis Memo the efforts initiated by Hirsh et al.
The experiential approach to SVT being limited only to what one saw and felt at the bedside is no longer appropriate or sustainable. Why clinicians continue to segregate SVT from all other venous thromboses is Thrombophlebitis Memo readily explainable, particularly now that the experimental approach has become dominant and prophylaxis and therapy are so effective. If thromboses of the visceral, cerebral, Thrombophlebitis Memo, renal, and pelvic veins fit well into our modern thinking of VTE, the time seems right to abandon anatomic location of a venous thrombosis as a special sanctuary having its own diagnostic niche, therapy, and separate clinical approach.
This confusion has obfuscated review of the literature, Thrombophlebitis Memo. The preponderance of reports and data on SVT involve thrombosis of the long saphenous vein, the longer proximal part of which is the GSV the now-preferred term and the smaller, more distal part, the lesser saphenous vein, Thrombophlebitis Memo.
The time has come to eliminate this nomenclature; no reason to support retention of this misleading term has been advocated by any professional organization.
Third, superficial veins also include the veins that occur anywhere superficially on the body whether they are on the abdominal wall, thoracic wall, or arms. These painful thromboses may be collaterals of deeper occluded veins, such as the inferior vena cava or deep veins of the arm.
That all these terminologies, incorrect usages of anatomic terms, and incomplete studies are confusing issues was deduced by the Cochrane Collaboration systemic review of SVT by DiNisio et al. They noted that, Thrombophlebitis Memo, although SVT had long been regarded as a fairly benign disease, that stance has been increasingly called into question. The lack of clinical trials combined with the frequency that clinicians encounter SVT has resulted in this paper of how I perceive, Thrombophlebitis Memo, approach, and treat SVT in clinical practice, Thrombophlebitis Memo.
The few available studies are heterogeneous and descriptive in nature, and follow-up of patients is so limited that meaningful recommendations cannot be gleaned from the existing literature. Because most reports specifically excluded patients having known concomitant DVT and PE, excluded patients with prior DVTs and PEs, excluded those with family histories positive for DVT, and excluded those who had ever been treated with anticoagulant therapy, Thrombophlebitis Memo, generalization of these data to one's own SVT patients may be flawed in that those results might be too benign as these real risk factors had been eliminated in the study group.
These approaches are not compatible with our current view that VTE Thrombophlebitis Memo best regarded as systemic, Thrombophlebitis Memo, chronic, Thrombophlebitis Memo often familial rather than isolated, acute, and random.
Using modern imaging techniques prospectively at the time of a clinical diagnosis, Chengelis et al 21 studied the progression of thrombosis between day 2 and day 10 average, 6. Recently, in a cross-sectional prospective cohort study, Decousus et al 24 prospectively described such data among SVT patients.
Multiple studies written in the last decade warum trophic Ulkusschmerzes demonstrated enrichment of thrombophilia among patients diagnosed with SVT. Among their strongest risk factors were the hypercoagulable states to include Thrombophlebitis Memo as well as malignancy. Other risk factors included aging and impaired blood flow from obesity, pregnancy, or even prolonged air travel.
Heit et al 27 were the first to note that a prior history of Thrombophlebitis Memo served as an independent risk factor for the Thrombophlebitis Memo development of DVT, again linking etiology.
Their observation was confirmed by Schönauer et al. Thus, I regard SVT as simply the superficial venous manifestation of a systemic process that is associated with what is more commonly called VTE. There is no therapy for SVT that is agreed on and, given the wide variety of options and the lack of randomized clinical trials, Thrombophlebitis Memo, one may deduce that a clear and effective evidence-based therapy is not currently available 14 Table 2. Clinical observation coupled with strict bed rest with complete immobility was recommended in the past as therapy for SVT by many authorities.
Such passive therapy may have seemed effective in part because relief of pain and swelling generated by SVT was the predominant endpoint.
Once serial measuring for either regression or progression of the SVT became available, first by venography and then by plethysmography and now by ultrasound, it was rational to observe patients for evidence of progression, treating with heparin only those who demonstrated progression.
There are still some patients for whom observation and serial ultrasounds every 5 to 7 days may be appropriate, but these appear to be the minority of patients. These might include those patients in whom anticoagulant therapy might be effective yet pose excessive risk such as patients with severe thrombocytopenia or concomitant ongoing hemorrhage or patients perceived to be at lower risk Thrombophlebitis Memo further thrombosis such as patients with Thrombophlebitis Memo prior personal or family history of thrombosis and those having no other clinical hypercoagulability risk factors, such as malignancy, immobilization, or concurrent inflammatory Thrombophlebitis Memo. Several reports have advocated that ultrasonographic imaging be routinely made for evidence of thrombosis more extensive than just the observable SVT, Thrombophlebitis Memo.
Such logic hinges on the belief that any thrombosis discovered above and beyond the SVT should be systemically treated, Thrombophlebitis Memo, whereas those cases of SVT existing alone should not be systemically treated.
That many patients' Thrombophlebitis Memo SVT might soon progress also implies that one must periodically reimage to observe for evidence of progression, Thrombophlebitis Memo. Many publications have also suggested that laboratory searches for thrombophilia should be Thrombophlebitis Memo out, the logic of which is based solely on the concept that such findings would alone and critically change one's therapeutic intent. Were one rather to deduce that the SVT itself, whether alone or coexisting with Thrombophlebitis Memo VTE, warranted anticoagulant therapy, complete initial imaging, serial imaging, Thrombophlebitis Memo, and laboratory testing could be abrogated, thus limiting expense.
Any known or unknown coexisting thrombosis would be treated by incorporation if one selects to use systemic anticoagulant therapy of their SVT patients. Nonsteroidal anti-inflammatory drugs have traditionally been used either orally or topically.
This approach seems to be in doubt because, even if inflammatory manifestations of SVT markedly respond to either time, the administration of nonsteroidal anti-inflammatory drugs, or the combination, such symptomatic improvement does not necessarily indicate that clot progression has been mitigated. Some physicians frequently apply topical anticoagulants in the form of heparin Thrombophlebitis Memo. For a century, surgical procedures have been used to treat thrombosis of the GSV.
The basis of this approach was that, if the proximal end of the clot approaches within a few centimeters of, let alone passes into, Thrombophlebitis Memo, the junction of the GSV with the femoral vein, the risk of possible embolism became serious enough to warrant surgical intervention. Surgical approaches involved a variety of procedures, ranging from ligation of the GSV, surgical removal of thrombus in the GSV, surgical excision of the entire GSV, and multiple diverse surgical procedures.
To the extent that one thinks Thrombophlebitis Memo especially with regard to causationone sees this surgical approach has limited credibility. Surgery itself serves an enormous impetus 27 for additional thrombosis.
Medical treatment is now recommended over surgical treatment. Several groups have proposed heparin-based therapy, Thrombophlebitis Memo, to include unfractionated heparin or low molecular weight heparins, and most recently pentasaccharide.
These reports used Ödeme in den Beinen und Krampfadern doses rather than commitment to full therapeutic dosage. With those 2 limitations too low intensity for too brief a periodit remains surprising that any benefit was observed. The Cochrane Collaborative reviewers concluded that any treatment with any anticoagulant over any period of Thrombophlebitis Memo not only seemed logical but resulted in trends toward efficacy.
Thrombophlebitis Memo, the Cochrane Collaborative reviewers documented negligible bleeding complications with anticoagulant therapy. A recent retrospective cohort study of patients cited no increase in stroke or myocardial infarction, yet a wie Blutegel Krampfadern zu behandeln increase in DVT Thrombophlebitis Memo patients with spontaneous SVT suggested anticoagulant therapy be withheld.
Lozano et Thrombophlebitis Memo 31 compared surgical and medical treatment of a group of patients with SVT, Thrombophlebitis Memo. The medical group received 4 weeks of moderately intensive enoxaparin therapy, whereas the surgical group underwent saphenofemoral surgical disconnection. Their selection process excluded Thrombophlebitis Memo patients who one sees in actual clinical practice, such as those patients with probable or known hypercoagulability, patients with known prior DVT and PE, Thrombophlebitis Memo, patients with malignancy, and patients with renal failure.
Patients were randomized between a prophylactic dose of fondaparinux 2. Patients were treated for 45 days the longest treatment group studied thus far and then followed for the subsequent 30 days off treatment. The study showed that, at 45 days, the treatment group had developed the primary endpoint of progression of thrombosis at a rate of 0. The CALISTO investigators also noticed the extremely low rate reported bleeding and concluded that such therapy Thrombophlebitis Memo rational, Thrombophlebitis Memo, effective, and durable after cessation of the fondaparinux therapy.
If Thrombophlebitis Memo elects not to offer therapeutic anticoagulant therapy, Thrombophlebitis Memo, consideration must include risks of coexistence of VTE, progression of VTE, Thrombophlebitis Memo, development and advancement of postphlebitic syndrome, Thrombophlebitis Memo, and ultimately fatal PE.
One must be mindful that many of at-risk patients with a clinical diagnosis of SVT in their practice may be the ones excluded from most reports, implying that, in one's clinic, results might actually be significantly better yet sparing the expenses of laboratory testing or serial ultrasound examination in most SVT patients.
One can now logically argue to preemptively treat patients, even if one perceives thrombosis is limited to the SVT stage. VTE risks are higher for an untoward event in untreated patients, especially if their history suggests a significant personal or family VTE history, the presence or likelihood of underlying malignancy, or limited cardiovascular and respiratory reserve to such an extent that even a modest-sized PE may prove fatal. Thrombophlebitis Memo can risk-stratify our patients using current risk factors and knowledge of SVT as herein reviewed to determine whether systemic anticoagulant therapy is warranted.
Admittedly, with the exception of the Decousus et al report, 34 there are no high-grade evidence-based data currently available. Clinical considerations include the size of the thrombosed vessel, whether there was provocation, history of recurrence, history of Thrombophlebitis Memo treatment with anticoagulant therapy for VTE, family history, known thrombophilia, and overall perceived risk of a PE to this patient, Thrombophlebitis Memo.
The gestalt of the situation will typically Thrombophlebitis Memo one to decide for or against systemic anticoagulant therapy.
Consider a patient who had dental work and peripheral intravenous lines inserted into the veins of the back of his hand resulting in a thrombosis extending into his veins of the upper arm.
If he were known to have had a prior DVT and administration of anticoagulants for a year after a PE related to a broken leg 10 years ago, Thrombophlebitis Memo, I would consider anticoagulant therapy for him for the next 3 months, Thrombophlebitis Memo, based on my perception that he is hypercoagulable and this small untreated thrombus could provoke a VTE elsewhere in such a patient.
In a second scenario, an obese year-old woman with active inflammatory bowel disease develops a cm, Thrombophlebitis Memo, tender, warm cord in her left GSV as her initial experience with thrombosis after several weeks of near total bed rest.
I would prescribe 6 months of anticoagulant therapy Thrombophlebitis Memo even longer should her inflammatory bowel disease remain active. In the routine treatment of patients with DVT lacking symptoms of PE, imaging studies to document the presence of PE are generally not held as necessary as the decision to treat with systemic anticoagulant therapy is sufficient with DVT alone. Accordingly, I do not routinely repeatedly and serially and exhaustively image patients with SVT as I hold that those patients have reason enough to be treated with systemic anticoagulation, saving a significant amount of time and expense.
Such an approach can be modified if symptoms so suggest. Thrombophlebitis Memo, I would perform laboratory testing for thrombophilia only in situations that I thought might change the type of therapy, Thrombophlebitis Memo, the duration of the therapy, or if such would have any clinical impact Thrombophlebitis Memo the patient or especially his family members. One anxiously awaits randomized controlled trials to document the validity of these suggestions, but until that time it seems efficacious and safe to regard the majority of SVTs, particularly those of the long saphenous vein, as being of potential danger and worthy of anticoagulant therapy.
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Abstract Thrombosis of superficial veins has long been regarded as a benign disorder, Thrombophlebitis Memo. What exactly is and is not SVT?
View inline View popup. Table 2 Therapeutic considerations for patients with SVT, Thrombophlebitis Memo. A method of managing superficial thrombophlebitis. Surgery ;
Phlebitis and Thrombophlebitis Thrombophlebitis Memo
Varizen stark anschwillt Bein throm-boe-fluh-BY-tis is an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. The affected vein might be near the Thrombophlebitis Memo of your skin superficial thrombophlebitis or deep within a muscle deep vein thrombosis, or DVT.
Causes include trauma, surgery or prolonged inactivity. DVT increases your risk of serious health problems. It's usually treated with blood-thinning medications. Superficial thrombophlebitis is sometimes treated with blood-thinning medications, too. When a vein close to the surface of your skin is affected, you might see a red, hard cord just under the surface of your skin that's tender to the touch.
When a deep vein Thrombophlebitis Memo the leg is affected, your leg may become swollen, tender and painful, Thrombophlebitis Memo. See your doctor right away if you have a Thrombophlebitis Memo, swollen or tender vein — especially if you have one or more risk factors for thrombophlebitis.
If you have leg swelling and pain and develop shortness of breath or chest pain that worsens when you breathe, go to an emergency room. These might indicate that you have a dislodged blood clot traveling through your veins to your lungs pulmonary embolism, Thrombophlebitis Memo.
If you have one or more risk factors, discuss prevention strategies with your doctor before Thrombophlebitis Memo long flights or road trips or if you're planning to have elective surgery, recovery from which will require you not to move much. Pulmonary embolism occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung.
Blood clots most often Thrombophlebitis Memo in the legs and travel up through the right side of the heart and into the lungs. Complications from superficial thrombophlebitis are rare. However, if you develop DVT, the risk of serious complications increases, Thrombophlebitis Memo. Sitting during a long flight or car ride can cause your ankles and calves to swell and increases your risk of thrombophlebitis. To help prevent a blood clot:.
Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission, Thrombophlebitis Memo. This content does not have an English version. Blood clot in leg vein A blood clot in a leg vein may cause pain, warmth and tenderness in the affected area. Request an Appointment at Mayo Clinic. Pulmonary embolism Pulmonary embolism occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung.
References Nasr H, Thrombophlebitis Memo, et al. Superficial thrombophlebitis superficial venous thrombosis. Scovell S, et al. Phlebitis and thrombosis of the superficial lower extremity veins. Accessed July 11, Approach to the diagnosis and therapy of a lower extremity deep vein thrombosis, Thrombophlebitis Memo.
Di Nisio M, et al. Treatment for superficial thrombophlebitis of the leg review. Cochrane Database of Systemic Reviews. National Heart, Lung, and Blood Institute.
Alguire PC, et al, Thrombophlebitis Memo. What is it used for? Mayo Clinic Store Check out these best-sellers and special offers on books and newsletters from Varizen Tunika Clinic.