Acute GP service
Cornwall
This is a site intended for clinicians - all guidelines must be interpreted in the context of clinical risk assessment
Superficial thrombophlebitis guidelines
Superficial venous thrombosis or thrombophlebitis (STP) in the lower limb is a relatively common, painful, and in many cases self-limiting condition. It can be sterile (majority of cases, associated with varicose veins), infective/traumatic (associated with trauma or cannulation, antibiotics may have a place) or migratory (rare, consider paraneoplastic cause).
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Around 10-21% of patients with STP will already have DVT at presentation and a further 3-4% will progress to it if untreated. Patients with at least 5 cm of thrombus in a superficial vein are more likely to have underlying DVT if the STP is in the proximal long saphenous vein (within 10 cm of the saphenofemoral junction). Sterile STP within a varicose vein is less likely to be associated with underlying DVT. D-dimer is of no value, it may be elevated in both.
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Patients with clinical signs of superficial thrombophlebitis affecting the proximal (above knee) long saphenous vein should have an ultrasound scan to exclude concurrent DVT.
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Patients with STP within 3cm of the sapheno-femoral junction should be considered for therapeutic anticoagulation
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Patients with superficial thrombophlebitis, without DVT, should have anti-embolism stockings and, if extending above the knee, be considered for treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days (JAMA 2018;320:2367). The absolute benefit of this strategy is small, with a NNT of 90. DOACs are not licensed for this indication but have been used.
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If LMWH is contraindicated, or where the STP is confined to the calf, 8-12 days of oral NSAIDs should be offered. This reduces risk of extension and recurrence of STP but not DVT/PE risk.
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There is insufficient evidence to support the use of topical heparinoids
Taken from the BCSH guidelines, page 7