Superficial Vein Thrombosis: A Review

Importance: Superficial vein thrombosis (SuVT) is characterized by thrombus in the superficial veins, typically in the lower or upper extremities, and has an estimated annual incidence of 64 to 131 per 100 000 person-years. Approximately 10% of patients with SuVT progress to deep vein thrombosis (DVT) or pulmonary embolism (PE).

Observations: Endothelial injury (caused by infection or intravenous devices), venous stasis (such as from chronic venous insufficiency or prolonged immobility), and hypercoagulability (due to cancer or pregnancy) are pathophysiologic factors associated with SuVT. Clinical risk factors for lower extremity SuVT are similar to those of DVT and PE and include pregnancy, varicose veins, and active cancer. The incidence of SuVT is greater in females than males (78-167 compared with 49-116 per 100 000 person-years). In contrast with lower extremity SuVT, upper extremity SuVT is primarily caused by indwelling intravenous catheters. Patients typically present with a tender, red, palpable cord under the skin in the upper or lower extremity. D-dimer testing has a sensitivity of approximately 48% to 74.3% and, therefore, is not reliable for excluding SuVT. Approximately 25% of patients with lower extremity SuVT present with concomitant DVT, likely because risk factors for SuVT and DVT are similar and because SuVT can extend into deep veins. In people without classic symptoms and signs of SuVT, ultrasonography can establish the presence and extent of the thrombus. Management may include elastic compression stockings and nonsteroidal anti-inflammatory drugs. For patients with SuVTs that are at least 5 cm long or those with persistent or worsening symptoms despite several days of conservative therapy, treatment includes anticoagulation with fondaparinux 2.5 mg. Alternative anticoagulation treatment includes rivaroxaban 10 mg once daily and low-molecular-weight heparins (eg, enoxaparin 40 mg once daily), which may reduce subsequent venous thromboembolic events. SuVT located within 3 cm of a deep vein should be treated with therapeutic doses of anticoagulation such as direct oral anticoagulants.

Conclusions and relevance: SuVT typically presents as a tender, painful, palpable cord under the skin. Management may include elastic compression stockings, nonsteroidal anti-inflammatory drugs, and systemic anticoagulation with fondaparinux 2.5 mg or rivaroxaban 10 mg. SuVTs within 3 cm of a deep vein should be treated with therapeutic dose anticoagulation.

Author/s:

Gregory Piazza, Darsiya Krishnathasan, Nada Hamade

Treatment of Superficial Vein Thrombosis: A Systematic Review and Meta-Analysis

Jeffrey Wilson — Wed, 03 Apr 2019 14:13:21 +0000

Date Added:

April 3, 2019

Journal/Publication:

Journal of Thrombosis and Haemostasis

Publisher:

Wiley-Blackwell

Publication Date:

March 1, 2019

Issue:

Volume:

119

Pages:

479-489

URL:

Treatment of Superficial Vein Thrombosis: A Systematic Review and Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1055/s-0039-1677793

Keywords

PMID (1):

30716777

MeSH

venous thrombosis

pulmonary embolism

fondaparinux

This meta-analysis calculated that superficial thrombosis occurring in the lower extremity was associated with a 10% rate of deep vein thrombosis and/or PE. Treatment with fondaparinux (Arixstra) lowered the risk to 1.4%. They found insufficient evidence to support other treatments. James W. Mold, MD, MPH

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BACKGROUND:

The optimal first line treatment for patients with isolated superficial venous thrombosis (SVT) of the lower extremity is unknown.

OBJECTIVE:

This article reports estimates of the rate of venous thromboembolic complications among patients with SVT according to treatment.

MATERIALS AND METHODS:

A systematic review and meta-analysis was performed using unrestricted searches of electronic databases. Reported events were transformed to event per 100 patient-years of follow-up and a random effects model was used to calculate pooled rates according to pre-specified treatment categories. The primary outcome was the occurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE) during the study follow-up period.

RESULTS:

Seventeen articles, including 6,862 patients, were included in the meta-analysis. Fondaparinux had the lowest event rate with 1.4 events per 100 patient-years of follow-up (95% confidence interval [CI], 0.5-2.8, I 2 = 18%). Pooled event rates for DVT or PE ranged from 9.3 to 16.6 events per 100 patient-years across other treatment categories, and the pooled event rate for no treatment/placebo was 10.5 events per 100 patient-years (95% CI, 3.0-22.0). Major bleeding was low and similar across all treatment categories. Heterogeneity was moderate to high for most pooled estimates.

CONCLUSION:

While pooled event rates suggest that fondaparinux achieves the lowest rate of DVT or PE, low-quality evidence for other treatments prevents firm conclusions about the optimal treatment for SVT.

Author/s:

Duffett, Lisa, Kearon, Clive, Rodger, Marc, Carrier, Marc