Suman Rathbun MD, MS Professor of Medicine Director, … · Suman Rathbun MD, MS Professor of...

Suman Rathbun MD, MSProfessor of MedicineDirector, Vascular MedicineUniversity of Oklahoma Health Sciences Center

¡ No relevant disclosures

¡ Epidemiology¡ Clinical Presentation¡ Diagnosis¡ Treatment

-Medical-Surgical-Topical-Clinical trials

¡ More common than DVT 1:1000¡ Estimated 3 to 8% of the general population¡ Risk factors: varicose veins, immobilization, trauma, surgery,

pregnancy and post-partum, hormonal contraception or replacement therapy, increasing age, obesity, history of VTE, malignancy, autoimmune disease, thrombophilia, IV catheter

¡ Females>Males

¡ Varicose veins¡ Traumatic¡ Septic and Suppurative¡ Migratory¡ Mondor’s Disease¡ Small saphenous¡ Upper extremity¡ Post endovascular vein treatment

Varicose vein SVT• Most common risk factor for SVT• Lower risk of progression to DVT• May be precipitated by trauma• Tender nodules• Localized induration• More common after foam sclera vs. thermal ablation

• Infusion therapy• Direct endothelial injury of irritating solutions• Pain, tenderness and erythema at catheter insertion• Vein may contract rather than recanalize

Septic thrombophlebitis

• IV lines with septicemia• Leukocytosis• Intense pain• Staph aureus, Pseudomonas, Klebsiella, Candida• Removal of catheter; IV antibiotics• Excision of vein in rare cases

At presentation 3 month follow-up

Mondor’s disease

• Thoracoepigastric vein of the breast/chest wall• Breast carcinoma or hypercoagulable states• Benign and self limited• NSAIDs

Great/Small Saphenous Vein SVT

• Can progress to common femoral or popliteal DVT• Similar morbidity with GSV or SSV SVT

Upper extremity IV line related SVT

• Caustic substance with direct injury to endothelium• Basilic or cephalic veins• Rare progression to DVT• Catheter removal; occasional anticoagulation

¡ Compression ultrasound

¡ Reduce or ameliorate symptoms¡ Prevent progression to DVT¡ Prevent PE¡ Prevent recurrence/QOL

Treatment Options:¡ Topical¡ Pharmacological systemic: Anticoagulation, NSAID¡ Surgical

SVT TREATMENT — Treatment differs depending upon whether the thrombosis affects the tributaries (superficial thrombophlebitis) or axial veins (ie, great or small saphenous veins) indicative of superficial vein thrombosis (SVT), and whether or not there are complications.

Approach to treatment — Treatment of superficial phlebitis is primarily aimed at alleviating symptoms and preventing propagation of thrombus into the deep venous system.

Uncomplicated — Initial management of uncomplicated thrombophlebitis and less extensive SVT (ie, affected vein segment <5 cm, remote from saphenofemoral/saphenopopliteal junction, no medical risk factors) is supportive and consists of extremity elevation (ie, waist level), warm or cool compresses, nonsteroidal anti-inflammatory drugs (NSAIDs), and possibly compression therapy [46]. The patient should be encouraged to remain ambulatory if possible. Antibiotic treatment is not indicated in the absence of signs of infection (eg, high fever, purulent drainage) [47]. (See 'Symptomatic care' below.)

Anticoagulation is suggested for patients with more extensive superficial thrombophlebitis, particularly those with SVT approaching the deep venous system via the saphenofemoral junction, because of a higher risk for developing a deep vein thrombosis (DVT) [21,37,41,48-50]. A decision to anticoagulate the patient when thrombus approaches the deep venous system at other sites (ie, saphenopopliteal junction, perforator veins) should be individualized; either anticoagulation or serial duplex ultrasound may be appropriate. Anticoagulation is also appropriate for those patients who demonstrate propagation. (See 'Anticoagulation' below.)

An exception to the need for anticoagulation is the patient with superficial vein thrombosis following endovenous ablation therapy. The natural history of endovenousheat-induced thrombus (EHIT) appears to be more benign than spontaneous thrombus with less of a propensity for embolization [7]. EHIT is generally managed conservatively. (See "Radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Deep venous thrombosis' and 'Anticoagulation' below.)

Up to Date Sept 29,2015

¡ LMWH-Titon-VESALIO-CALISTO-STEFLUX

¡ LMWH vs. NSAID-STENOX-Rathbun

Study Patients Intervention Outcome

Titon1994

117 RCT+ compress6 days

Nadro 6150 IUNadro 31.5 IU/kgNaprox 500 mg

2.6% STP5% STP2.6% STPNo DVT,PE, bleed

STENOX2003

436 RCTSTP > 5 cm+ compress8-12 days

Enox 40 qdEnox 1.5mg/kgTenoxicam 20Placebo

0.9/8.3% DVT/STP, 0 PE 0.9/5.7 % DVT/STP, 0 PE2.0/13.1% DVT/STP, 1 PE3.6/29.5% DVT/STP, 0 PE

Vesalio2005

164 RCTSTP >3cmfrom jx

Nadroparin 2850 Nadro

Titon J. Annales de cardiologie et d’angeiologie 1994;43:160-6STENOX study group. Arch Intern Med 2003;163:157-63

Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004982. DOI:

10.1002/14651858.CD004982.pub5.

LMWH vs. NSAID forPrevention of VTE

Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004982. DOI: 10.1002/14651858.CD004982.pub5.

¡ LMWH and NSAIDs reduced the incidence of extension or recurrence of SVT but no effect on VTE

¡ Topical treatments relieved local symptoms but trials did not report progression to VTE

¡ Surgical treatments and wearing elastic stockings were associated with lower VTE and VTE compared to stockings alone

¡ Methodological quality of the 30 studies assessed was poor overall.¡ No differences in major bleeding but NSAID with increased

gastrointestinal side effects

¡ Double-blind RCT¡ 3002 received either fondaparinux (2.5mg/day) or placebo X

45 days¡ Primary efficacy outcome: composite of death from any cause

or symptomatic pulmonary embolism, symptomatic deep-vein thrombosis, or symptomatic, extension to the saphenofemoral junction or symptomatic recurrence of STP at day 47

¡ Main safety outcome - major bleeding¡ Follow up to day 77

Major bleeding occurred in one patient in each groupIncidence of serious adverse events was 0.7% with fondaparinux and 1.1% with placebo

A=parnaparin 8500 IU qd X 10 days + placebo 20 daysB=parnaparin 8500 IU qd X 10 days + 6400 IU 20 daysC=parnaparin 4250 qd for 30 days

The objective of this study was to assess the efficacy, safety, and cost of low-molecularweight heparin compared to saphenofemoral disconnection for the treatment of internal saphenous proximal thrombophlebitis (SPT). Eighty-four consecutive patients diagnosed as presenting SPT alone (symptoms/echo-Doppler) were divided into 2 comparable groups treated with (1) saphenofemoral disconnection under local anesthesia with a short hospital stay (n=45) or (2) prospective enoxaparin on an outpatient basis for 4 weeks (n=39). Informed consent was obtained and inclusion, exclusion, and withdrawal criteria were established. Patients were followed up at 1, 3, and 6 months. Thirty patients per group completed the study requirements. In thedisconnection group, 2 patients (6.7%) presented complications of the surgical wound, 1 (3.3%) had SPT recurrence (however, there was no deep venous thrombosis), and 2 (6.7%) had nonfatal pulmonary embolism confirmed by radionuclide scan. In the

enoxaparin group, there were 2 cases (6.7%) of minor bleeding (epistaxis and rectal bleeding) and 3 (10%) recurrences of SPT. In the enoxaparin group there was no case of progression of the thrombosis to the deep venous system or pulmonary embolism. The study found no statistically significant differences between saphenofemoral disconnection and enoxaparin in the treatment of SPT, but the low-molecular-weight heparin group had socioeconomic advantages.

Low-Molecular-Weight Heparin Versus SaphenofemoralDisconnection for the Treatment of Above-Knee Greater Saphenous Thrombophlebitis: A Prospective Study Francisco S. Lozano, MD, PhD and Arturo Almazan, MD, PhD, Salamanca, Sp

Vascular and Endovascular Surgery Volume 37, Number 6, 2003

DVT

Thrombus at 21 days

DOI: 10.1002/14651858.CD004982.pub5

Superficial Vein Thrombosis (SVT) Treated With Rivaroxaban Versus FondaparinuxThis study is currently recruiting participants. (see Contacts and Locations)Verified December 2015 by GWT-TUD GmbHSponsor:GWT-TUD GmbHCollaborator:BayerInformation provided by (Responsible Party):GWT-TUD GmbHClinicalTrials.gov Identifier:NCT01499953First received: December 19, 2011Last updated: December 3, 2015Last verified: December 2015History of Changes

Rivaroxaban Anticoagulation for Superficial Vein Thrombosis (RASET)This study is currently recruiting participants. (see Contacts and Locations)Verified January 2016 by McMaster UniversitySponsor:McMaster UniversityCollaborator:BayerInformation provided by (Responsible Party):McMaster UniversityClinicalTrials.gov Identifier:NCT02123524First received: April 23, 2014Last updated: January 19, 2016Last verified: January 2016History of Changes

Efficacy and Tolerability of Hirudoid Cream in Prophylaxis and Treatment Infusion PhlebitisThis study is currently recruiting participants. (see Contacts and Locations)Verified September 2015 by Medinova AGSponsor:Medinova AGInformation provided by (Responsible Party):Medinova AGClinicalTrials.gov Identifier:NCT01943006First received: September 6, 2013Last updated: September 23, 2015Last verified: September 2015History of Changes

¡ LMWH or NSAID effective for reducing pain and extension/VTE but risk stratification model not available

¡ Compression alone not effective for preventing extension¡ Surgery provides symptom relief but may not reduce extension¡ ACCP 2012 recommendation (no change 2016):

Superficial thrombosis ≥ 5 cm in length should receive prophylactic dose fondaparinux or LMWH for 45 days (2B). Fondaparinux 2.5 mg is preferred over LMWH (2C).

¡ Goals of treatment met by LMWHbut dose and duration of LMWH not clear