Management of patients with superficial ... - RM Solutions

Management of patients with
superficial thrombophlebitis
Mateja Kaja Jezovnik, M.D., PhD.
Prof. Pavel Poredos, M.D., PhD.
University Medical Centre Ljubljana
Department of Vascular Disease
Definition
• Superficial thrombophlebitis (ST) is an inflammation of
the venous wall with subsequent secondary clot
formation
• Most frequently affects superficial veins of lower limbs
• Thrombophlebitis
• Superficial vein thrombosis
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Clinical presentation
REDNESS
PAIN
EDEMA
WARM SKIN
Epidemiology
• Incidence in the general population: 3-11%
May be underestimated t d (pts with minor symptoms,
not present for medical attention)
• Female/male ratio: 6 to 4
• Mean age of presentation: 60 yrs
• Often two or more factors have to be present
• Age - the older the patient, the higher the prevalence
DeWeese, 1991; Nordstrom 1992, Ramelet 2008
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Etiology
• Hypercoagulability
• Cancer
• Pregnancy, puerperium, oral contraceptives, hormone
replacement therapy
• Antiphospholipid syndrome
• Thrombophilia
• Reduced blood flow
• Varicosities – injury of the venous valves
• immobility
• Damage of the vessel wall
• Surgical procedures, trauma, i.v. catheters
t
• Other
• AGE > 60 years
• OBESITAS
• History of VTE or SF
Virchow
triad
Leon LR Jr et al. Perspect Vasc Surg Endvasc Ther, 2005
Primary Superficial
Thrombophlebitis
• Pathogenesis es s is not known, however e there e are
some supposed pathogenetic mechanisms:
• Damage - inflammation
• Varicose veins - VARICOPHLEBITIS (4 - 59%, bilateral 5
– 10%)
• Hypercoagulable states
• Prevalence of hypercoagulable state t in ST is high
h
(up to 72% in patients without varicose veins)
• Factor V Leiden Mutation, Factor II G20210A
mutation, antithrombin, protein C and S
deficiency
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Secondary Superficial
Thrombophlebitis
• accompanied by systemic (inflammatory)
disease and is related to the damage of the
vascular wall
• Mb. Bürger
• Behçet’s et’s disease
• Vasculitis and rheumatic syndromes (APLS)
• Malignant tumours
• “SEPTIC” TF ASSOCIATED WITH VENOUS CATHETERS (i.v.
application in drug users, i.v. catheters in immunocompromised
patients)
• “STERILE” TF
• i.v. drug application
The Clinical Importance of ST
• traditionally ST has been considered a
relatively l benign and self - limited it disease
• systemic diagnostic investigation (US) of
patients with ST revealed interrelationship
between ST and VTE, therefore it was
recently accepted as an integral part of
venous thromboembolic syndrome
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The Incidence of VTE in
Patients with ST
Incidence:
• association between ST in DVT was found in 2% to
33%
Factors related to increased risk:
• protrusion of thrombus from superficial to deep venous
system
• the strongest association in patients with:
• thrombus in superficial veins near sapheno – femoral or
sapheno – popliteal junction (

US diagnostic
Thrombosis extension to SFJ
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Is There Preferential Treatment
of ST ?
• lack of evidence
– based data
a. Lack of consistency in the end points
b. Inadequate F-Up
c. Small number of patients
d. Limited evaluation to rule out VTE
e. Most of retrospective nature
• choice of therapy is influenced by:
- symptoms and progression of the disease
- patients preference
- available medical resources
Actual treatment of ST
• Compression
• Bandages
• Stockings
• Normal physical activity
• Walking with elastic compression, not bed rest
• Drugs
• Anticoagulants – low molecular weight heparins (LMWH),
UFH, oral anticoagulants
• The role of non-steroidal anti-inflammatoryinflammatory drugs (NSAIDs)
and topical local anti-inflammatory inflammatory treatment (gel, cream,
spray) is not well defined, they alleviate the symptoms
• No place for antibiotics (except in patients with septic ST)
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The efficacy of LMWH and Nonsteroidal
anti-inflammatory inflammatory drugs
• LMWH better than NSAID in regard to thrombus extension
• a nonsignificant reduction in the incidence of VT and PE in the
LMWH group
Stenox study, Arch Intern Med 2003
Efficacy of LMWH
in
Treatment of ST
• both: preventive and therapeutic ti doses of
LMWH prevent extension and recurrence
of ST (QUENET et all J Vasc. Surg. 2003)
• there is a trend of lowering incidence of
thromboembolic events, however no
relevant study confirmed significant
reduction of VTE in patients with ST
treated with LMWH (Prandoni et al, J Thromb Haemost 2005)
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TREATMENT OF ST OF THE LEG
(THE COHRANE COLLABORATION)
• 2469 patients with ST
• treatment modalities: NSAIDs, topical treatment, surgery,
LMWH
• 70% reduction of extension or recurrences of the disease
in pts. treated with NSAID and LMWH in comparison to
placebo
• Any anticoagulant treatment over “any yp
period of time”
appear as the current best therapeutic option for ST of the
legs
• in spite of nonsignificant effect of LMWH on VTE
complications, they concluded that an intermediate LMWH
for at least 1 month might be advised
Cohrane Review 2007
Fondaparinux for the Treatment of
Superficial-Vein Thrombosis in the Legs
• randomized,
double-blind blind trial:
CALISTO
• 3002 patients
• Fondaparinux 2.5
mg s.c. once daily
vs placebo for 45 d
• Follow Up- 77 days
Fondaparinux significantly reduced progression of
the disease and thrombotic complications
NEJM 2010
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Guidelines of the American College
of Chest Physicians ACCP
• patients with spontaneous ST
- prophylactic hl or intermediate doses of
LMWH for at least 4 weeks (Grade 2B)
- as an alternative UFH, warfarin (target INR
2.0 to 3.0) (Grade 2C)
- medical treatment with anticoagulants over
surgical treatment is recommended (Grade
1B)
-oral
nonsteroidal anti - inflammatory drugs
should not be used with anticoagulants
(Hirsch et al. CHEST 2008)
CONCLUSIONS
• ST is frequent and not benign
disease
• its ethiopathogenesis is based on
similar risk factors as DVT
• ST is related to DVT and is
accepted as a part of thrombotic
syndrome.
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CONCLUSIONS
• LMWH reduces progression and recurrence
of ST
• prevention of VTE complications was
confirmed only in one study, where pts were
treated with fondaparinux (CALISTO)
• therapeutic or intermediate doses of LMWH
for 4-6 weeks are recommended for
treatment of ST (actual guidelines)
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