Venous thrombosis superficial I80.9

Frequent, polyätiological, both localized and multilocular, circumscribed, painful inflammation of the venous wall of superficial (epifascial) veins, occurring in varices (varicophlebitis) as well as in normal veins. The inflammatory process is accompanied by partial or complete thrombotic occlusion of the epifascial vein.

Superficial thrombosis (thrombophlebitis of the epifascial venous system) is classified according to its type and frequency as follows:

• Superficial thrombophlebitis (as described here)
• Iatrogenic thrombophlebitis of the forearm (after injections or permanent needles)
• Varicophlebitis (superficial thrombophlebitis of a varicose vein)
• Thrombophlebitis migrans (saltans): intermittent phlebitis in a non-varicose vein.
• Mondor's disease (stranded phlebitis): superficial, stranded, compressive thrombophlebitis of the lateral throracic veins (Mondor's disease, stranded phlebitis)
• Crown-furrow phlebitis (special form of strand-like phlebitis, also known as non-venereal crown-furrow lymphangitis)

Triggering or occurrence, among other things, after general or local infections, after local trauma (e.g. after application of venous catheters) and toxic damage to the venous wall, in the case of prolonged immobilization, in chronic venous insufficiency and idiopathic (e.g. in migrating thrombophlebitis).

Especially superficial thrombophlebitis of non-varicose veins, which cannot be explained by an immediate process, requires clarification (exclusion of malignancy as paraneoplastic syndrome, Behçet's disease, endangitis obliterans).

If the etiology is not clear, thrombophilic diathesis should also be excluded.

• Most commonly on the forearms after intravenous injections.
• Thrombophlebitis of varicose veins is a consequence of venous stasis and is mainly located in the legs.

Circumscribed, reddened swelling over a coarse, strand-like palpable, pressure-tolerated vein. Depending on the severity of the clinical picture, a distinction is made between phlebitis exsudativa simplex and phlebitis suppurativa or gangraenosa. In case of a strong local inflammatory reaction, fever and disturbance of the general condition can occur.

Any suspicion of thrombosis of the V. saphena magna and/or V. saphena parva and their accessory veins should be clarified by duplex sonography. The decisive factors are a) the total length of the thrombus and b) the proximity of the thrombus to the deep vein system. In particular, if the superficial thrombosis is located proximally, a careful exclusion of deep thrombosis should be made.

• Septic phenomena
• postphlebitic ulcer
• Spreading to insufficient perforating veins or, in the case of the saphenous vein via Krosse (connection between the saphean vein and the femoral vein) to the femoral vein (approx. 20% of cases)
• Pulmonary embolism (about 4% of cases; according to POST study).

The therapy is carried out depending on the extent and localisation (see recommendations of the LL Diagnostics and Therapy of Deep Vein Thrombosis and Pulmonary Embolism, status 10/2015):

a) superficial venous thrombosis in small calibre branch varices: symptomatic therapy with cooling, compression therapy and non-steroidal anti-inflammatory drugs as required, if necessary a stab incision with thrombus expression

b) Varicothromboses of the V. saphena magna or parva and large calibre varicose branches: from a thrombus length of 5 cm in the truncal veins or larger lateral branches systemic anticoagulation - semi-therapeutic or therapeutic low molecular weight heparins (STEFLUX study) or prophylactic fondaparinux (2.5 mg/day s.c.) (CALISTO study). Approval of Fondaparinux in this indication with a recommended minimum treatment period of 4 weeks.

c) Approximation of the thrombus to less than 3 cm from an orifice valve to the deep venous system or, in the case of progression into the deep venous system: anticoagulation as in deep vein thrombosis

To date, there are no completed studies on the use of direct oral anticoagulants in this indication.

Anticoagulation is accompanied by compression treatment until the symptoms subside, usually over 3 months.

If superficial thrombophlebitis of the saphenous vein occurs on the floor of a varicose vein, the varicose vein must be repaired. The complication rate with initial conservative therapy and subsequent rehabilitation at symptom-free intervals proved to be lower than with immediate surgery.

Healing within 14-21 days with appropriate therapy.

1st guideline venous thrombosis and pulmonary embolism: diagnosis and therapy. http://www.awmf.org/uploads/tx_szleitlinien/065-002l_S2k_VTE_2016-01.pdf