Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 235-241

Superficial venous thrombosis: Single-center experience and current recommendations


Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission25-Apr-2019
Date of Decision18-Jun-2019
Date of Acceptance31-Jul-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Prabhu Premkumar
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_25_19

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  Abstract 


Introduction: Superficial venous thrombosis (SVT) is an underestimated and underreported disorder. Till date, there are no Indian epidemiological studies which have looked at the community or hospital prevalence rate of SVT. Patients and Methods: A retrospective cross-sectional study was done in the department of vascular surgery including all patients diagnosed and managed for SVT over the period of 2011–2018. All patients with deep vein thrombosis (DVT) were also screened for involvement of the superficial veins. The demographic data, imaging data, further management, and follow-up data were collected from the hospital records. The data were entered into EpiData software and Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA), and data analysis was done in R (version 3.5.0) and Microsoft Excel. Results: There were a total of 119 patients between the ages of 16 and 76 years. There were 84 men and 35 women. The median age of the entire study population was 46 ± 14.18 years. Eighty-one cases had only SVT, whereas 38 patients had both SVT and DVT together. 78 (65.5%) patients were diagnosed based on clinical presentation, whereas 41 (34.5%) patients were diagnosed on imaging done for other causes. In the patients diagnosed on clinical findings, 54 (69.2%) patients underwent a duplex ultrasound to rule out DVT. 77 (64.7%) patients were related to underlying varicose veins. 19% of patients had previous thromboembolic disease. The most common involvement was of the superficial veins in the patients who were clinically diagnosed. 54 (45.4%) patients received anticoagulation. Six patients had systemic venous thromboembolic complications. Conclusions: Anticoagulation should be the mainstay of treatment of patients with SVT. Prospective studies on superficial vein thrombosis are needed to assess and promote awareness of this condition in light of the current understanding of this potentially dangerous condition.

Keywords: Anticoagulation, deep vein thrombosis, pulmonary embolism, superficial vein, superficial venous thrombosis, thrombosis


How to cite this article:
Kalipatnapu S, Premkumar P, Selvaraj D, Agarwal S. Superficial venous thrombosis: Single-center experience and current recommendations. Indian J Vasc Endovasc Surg 2019;6:235-41

How to cite this URL:
Kalipatnapu S, Premkumar P, Selvaraj D, Agarwal S. Superficial venous thrombosis: Single-center experience and current recommendations. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Sep 27];6:235-41. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/235/273591




  Introduction Top


Superficial venous thrombosis (SVT), more commonly known by its previous name of “thrombophlebitis,” is essentially the inflammation that occurs secondary to thrombosis of superficial veins.[1],[2] An underestimated and underreported disorder, traditional teaching, had labeled it as a benign and self-limiting condition. However, new data on the natural history of this condition demand that this be included as a spectrum of venous thrombosis, along with pulmonary embolism (PE) and deep vein thrombosis (DVT).[1],[2],[3],[4]

Till date, there are no Indian epidemiological studies which have looked at the community or hospital prevalence rate of SVT.

This study aims to improve awareness of the current understanding of this condition. Toward that end, we present our data on the patient profile and the various management options used along with a summary of the current evidence.


  Patients and Methods Top


The study was approved by the institutional review board. A retrospective cross-sectional study design was used. All patients who were diagnosed and managed by the department of vascular surgery for superficial vein thrombosis during the period of 2011–2018 were included. All patients treated for DVT with thrombosis of superficial veins were also included.

At the outset, we would like to point out several limitations in this study. It was collected from a hospital and from a single department of vascular surgery. There was a significant loss of information as it was a retrospective study. The data were analyzed to present a picture of what had been seen. The prevalence of SVT was not recorded for arterial cases and in cases which were induced by intravenous (IV) catheters. These are common causes for SVT.[5] The authors would like to take this opportunity to point out the importance of recording even such “trivial” details into the patients' medical record. It is the authors' subjective experience that most cases of IV catheter-induced SVT remain undocumented and, hence, lost to understanding. This showcases the widespread hold of the “benign” understanding of SVT, which the authors aim to change.

The demographic data and imaging data, management, and follow-up data were collected from the hospital records. The data were entered into EpiData software[6], and Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA), and data analysis was done in R (version 3.5.0)[7] and Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA).


  Results Top


There were a total of 117 patients, 82 (72.65%) men and 35 (27.35%) women, between the ages of 16 and 76 years. The mean age was 45.33 ± 14.12 years. There were no cases of upper-limb SVT in our series.

All patients were divided into two groups on the basis of their clinical presentation and initial line of management – the first group was patients presenting with acute SVT (SVT-only group) and the second group who primarily presented with DVT but also found to have SVT (SVT and DVT group). In addition, a patient was noted to have “clinical” diagnosis when there was a clinical suspicion of SVT which was confirmed with a compression duplex ultrasound scan. An “imaging” diagnosis was when the patient was found to have SVT on imaging for either DVT or varicose veins with no clinical suspicion of the same. The details of these groups are summarized in [Table 1].
Table 1: Details of the study population

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Seventy-seven (65.8%) patients were associated with the presence of varicose veins. Twenty-three (19.7%) patients had a prior history of thromboembolic disease. Six patients had suspected prothrombotic conditions. Three of the six patients had hyperhomocysteinemia. Among the other three patients, two patients had a past history of recurrent DVT and the third patient had a history of prior mesenteric ischemia. Although a prothrombotic state was suspected based on exclusion, a full workup could not be done due to financial reasons.

Malignancy was suspected to be the cause in three patients. One was a female who had been diagnosed to have acute leukemia. The second was a female who presented with recurrent migratory SVT. On evaluation, she was found to have a bulky uterus. However, the pathology report after hysterectomy did not show any evidence of malignancy. Despite this, she was also put into this category as the clinical presentation can be best explained by an occult malignancy. The third was a female with multiple uterine fibroids. She also underwent a hysterectomy which was also reported as benign.

Among patients with infection as the suspected cause of the venous thrombosis, three patients presented with cellulitis, one patient had underlying chronic osteomyelitis, and one patient had ulcers on the leg. Nicotine exposure was seen in four patients. However, they did not have any concomitant arterial disease. Other risk factors are described in [Table 2].
Table 2: Risk factors of superficial venous thrombosis

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Fifty-three (45.4%) patients received anticoagulation in some form. A patient was counted as having received anticoagulation if he had received the drug for at least 4 weeks. The choice of anticoagulant was decided by the treating physician based on comorbid illnesses of the patient and its affordability. In case of Vitamin K antagonists (VKAs), the target international normalized ratio was kept at 2–3. With the advent and rise of the newer oral anticoagulants, they were used in patients in lieu of VKAs due to the ease of their dosing and lack of monitoring requirement. However, this was a very individualized decision made on a case-by-case basis. The most common class of drug used was the oral VKAs. The different anticoagulants used and the duration are shown in [Table 3] and [Table 4]. The use of low-molecular-weight heparin (LMWH)/fondaparinux was not seen in our sample. The duration of anticoagulation for each patient was decided by the treating physician. It has been our protocol that all patients with thrombosis are advised anticoagulation for a period of 3 months. In cases who also have a concurrent DVT, a low D-dimer was used as a marker to indicate cessation of active thrombotic activity. Only one patient, a 76-year-old female, with acute leukemia, from Group 2 did not receive anticoagulation as per her decision. All of the patients received anti-inflammatory drugs and analgesics. The local symptoms improved significantly, but some patients developed thromboembolic complications.
Table 3: Spectrum of anticoagulants used

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Table 4: Duration of anticoagulation

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Six patients developed systemic venous thromboembolic complications.

In the group with SVT only, three patients had PE and one patient had DVT. The first was a 66-year-old male who had presented with thrombus involving the proximal great saphenous vein (GSV). He underwent immediate ligation of the saphenofemoral junction (SFJ) and did not receive any long-term postoperative anticoagulation. The second was a 51-year-old female who had earlier presented with multiple episodes of migratory SVT. The third was a 48-year-old male who had presented earlier with recurrent DVT. He presented with acute isolated SVT and progressed to develop PE on anticoagulation.

From the second group, two patients had PE and two patients developed recurrent DVT. In this group, it is unclear if these complications are secondary to the SVT or the DVT.


  Discussion Top


The exact incidence of SVT is unclear, but it is more common in older people and in women.[8],[9],[10],[11] A large population study done in France showed that the incidence of lower-limb SVT is 0.64% per person-year in an adult population.[12] The most common veins involved include the great and short saphenous veins and their tributaries.[4] Group 1 in our study was predominantly men (70.58%) as compared to a study from Spain which had 60% women.[13] The risk factors for this condition seen in our population are similar to those found in studies from other countries around the world.[13]

In our study, only 54.12% of patients in Group 1 received anticoagulation. This is low compared to the Prospective Epidemiological Multicenter Cohort Study on Patients Clinically Suspected of Deep Vein Thrombosis or Pulmonary Embolism (OPTIMEV) study, in which 75% of patients received anticoagulation.[14] In patients with SVT only, 3/85 (3.5%) had PE. This is similar to other studies which have reported a range from 1.9% to 13.3%.[9],[12],[15] It has to be kept in mind that every patient in our series was not screened for PE.

Awareness of the importance of SVT is extremely important in its proper treatment. Over the past 10 years, the awareness has improved at our center.

Previous episodes of SVT with or without DVT increase the risk of subsequent SVT, but varicose veins remain the most common (88%) and clinically important etiological factor for SVT. A diagnosis of SVT should always prompt a search for varicose veins and should be treated if present.[16] In patients without cancer, an episode of isolated SVT was found to increase the risk of subsequent superficial venous thrombosis.[2]

It can be intuitively extrapolated that, in a patient with DVT, the chance of the thrombus extending into the superficial veins is quite high. In a patient who is found to have both SVT and DVT concurrently, it stands to debate as to which was the primary inciting factor. Although the immediate line of management would not be different, this differentiation may play an important role in evaluating potential etiology of the condition as well to aid in understanding the natural history of these life-threatening disorders. Hence, the authors feel it imperative to stress on the fact that isolated acute SVT should be treated appropriately and should be evaluated on par with a DVT.

In addition, in patients with clinical suspicion or diagnosed with DVT, it would help to proactively look for a superficial vein thrombosis and to document the same. The presence of a residual thrombus in the superficial vein after recanalization of the deep veins could be an inciting factor for recurrent venous thromboembolism (VTE) after completion of anticoagulation course in these patients.

Thromboangiitis obliterans (TAO) is a chronic inflammatory nonatherosclerotic thrombotic disorder of the medium- and small-sized arteries, commonly associated with smoking/tobacco consumption. SVT seen in the background of TAO has a different clinical course and treatment is primarily directed toward the arterial component.[3]

Risk factors

The myriad of risk factors involved in SVT can be broadly classified into three groups based on the Virchow's triad, as shown in [Table 5].[3]
Table 5: Risk factors for superficial venous thrombosis

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Classification

SVT can be classified based on the presence or absence of varicose veins as varicose vein SVT and nonvaricose SVT (NV-SVT) [Table 6].[3],[5] It can also be classified as primary or secondary. Primary SVT is when the thrombotic process involves only the affected vessels. Secondary SVT is when it occurs in the background of systemic inflammatory processes.[5]
Table 6: Classification of superficial venous thrombosis

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Diagnosis

Diagnosis of SVT is essentially clinical and is based on the findings of pain, tenderness, erythema, or induration overlying one or more superficial veins with or without fever and leukocytosis.[1],[3] The acute symptoms last for up to 3 weeks following which either fibrosis or recanalization of the vein occurs. This process could take up to 8 weeks.[3]

Complications

24%–29% of patients diagnosed with SVT have been found to have a concurrent, mostly asymptomatic DVT. Age >75 years, active cancer, ongoing hospital admission, and SVT on NV veins were found to be significant and independent risk factors for the same. This DVT could also be on the contralateral limb, and hence, a comprehensive duplex ultrasound of both lower limbs should be done in all patients with SVT.[15],[17]

In a study by van Langevelde et al., patients with a previously diagnosed SVT had the risk of DVT and PE six times and four times higher than an age-matched control with no prior history of SVT.[2] In patients diagnosed with isolated SVT without cancer, there was a 5.4% chance of recurrence of thromboembolic events every year and nearly half of them were recurrent SVT.[14]

Other complications include skin hyperpigmentation, local soft-tissue infection, and abscess formation.[1]

Management

Based on the current guidelines, a proposed algorithm for management has been depicted in [Figure 1]. Investigations in a patient with superficial thrombophlebitis are aimed at two possible goals:
Figure 1: Proposed algorithm for the management of superficial vein thrombosis. Axial veins = Great saphenous vein/saphenous vein in lower limbs

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  1. To delineate the anatomy of the thrombosis and to rule out deep vein involvement


    1. Duplex ultrasound – a combination of B mode ultrasound and Doppler evaluation. It is the initial investigation of choice due to its noninvasive and inexpensive nature[3]
    2. If concomitant varicose veins are noted, a formal venous duplex should be performed and further treatment should be planned for the varicose veins.


  2. To identify the cause of the thrombophlebitis[3]


    1. Test for acquired or congenital hypercoagulable states – most common ones include factor V Leiden mutation (16%); prothrombin G mutation (10%); and deficiencies in antithrombin III, protein C, or protein S (10%).[1]


    2. These conditions should be checked for in any patients following the exclusion of varicose veins, autoimmune disease, and malignancy.[18] Conditions that could be checked for include thrombin time, functional antithrombin level, clotting protein C and protein S assays, free protein S, activated protein C resistance, factor V Leiden, G20210A prothrombin gene mutation, C677T MTHFR gene mutation, FVIII levels, lupus anticoagulant, anticardiolipin and anti-beta 2 glycoprotein-I antibodies, and fasting plasma homocysteine levels.[13]
    3. Malignancies – In a study by Mouton et al., 12.9% of patients with SVT had an underlying malignancy.[19] Imaging should be directed toward identifying the primary malignancy. SVT is most commonly seen associated with adenocarcinoma of pancreas, carcinoma colon, breast malignancies, hematological malignancies, and skin cancer.[1],[19]


Role of serial duplex ultrasonography – There are no studies at present to clarify the exact timing and frequency of serial duplex ultrasound in patients who have been diagnosed with superficial vein thrombosis.

Role of D-dimer

D-dimer assay can be used to exclude DVT and PE. However, in patients with SVT, a positive assay was seen in only 68% of patients. This was not affected by the presence of varicose veins. Beyond a threshold thrombus volume of 5914 m3, all D-dimer tests were positive. Even though the sensitivity was at 100%, the sensitivity was only 29% (95% confidence interval: 19%–42%).[20] In a study of only upper-extremity SVT, D-dimer cutoff of <500 ng/ml was found to have a negative predictive value of 93% with a sensitivity of 77% and a specificity of 60%.[21] Furthermore, D-dimer is a nonspecific test and does not help differentiate SVT from DVT or PE.[1] However, D-dimer may have a role in the follow-up of SVT and to determine the duration of anticoagulation therapy. The PROLONG study suggests that anticoagulation may be safely stopped in patients with low D-dimer at 1 month following the index thrombotic event.[22],[23]

If the peripheral pulses are absent, further investigations should proceed in the evaluation of the arterial system.

Treatment

All therapies [Table 7] should aim to achieve the following goals:[1],[3]
Table 7: Treatment options used for superficial vein thrombosis

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  1. To decrease the acute symptoms, namely pain and erythema
  2. To prevent potential complications – local infection/DVT/PE/extension of SVT/recurrence of SVT.


The mainstay of treatment of all types of SVT is anticoagulation supplemented with nonsteroidal anti-inflammatory drugs (oral/topical), gentle compression, and mobilization as tolerated.[5] Antibiotics are also added in patients who have evidence of local infection.[1] In cases of acute SVT with erythema and swelling of the lower limb, the patient was given limb elevation, local magnesium sulfate application (to reduce the edema), and bed rest. When the SVT occurs in association with an infusion/IV catheter, there is no recommendation for anticoagulation.[24]

The 9th edition of the American College of Chest Physicians guidelines recommends the use of prophylactic anticoagulation with either LMWH or fondaparinux, if there is at least 5 cm of thrombus in the superficial vein. Additional indications for anticoagulation include involvement above the knee, particularly close to the SFJ, involvement of GSV, prior history of VTE or SVT, malignancy, recent surgery, and in anyone with extensive/severe symptoms of SVT.[24] The comparison of ARIXTRA™ in lower-limb superficial thrombophlebitis with placebo study proved the efficacy of fondaparinux (2.5 mg/day for 45 days) over placebo in reducing the risk of VTE, recurrent SVT, and extension of SVT.[25] There is currently no evidence of support the use of antiplatelet drugs in the management of SVT.[24]

Anticoagulation can be done with oral VKAs, fondaparinux, or LMWH. A systematic review comparing various anticoagulant agents supports the use of fondaparinux in prophylactic doses for a duration of 45 days.[26] The SURPRISE trial showed that rivaroxaban 10 mg OD is not inferior to fondaparinux 2.5 mg OD for 45 days in terms of efficacy and is not associated with higher rates of major bleeding.[27] However, at this point, there is not enough evidence of recommending the routine use of direct thrombin inhibitors or factor Xa inhibitors in the treatment of SVT.[5],[26]

Graduated compression therapy helps improve venous flow and local fibrinolytic activity. All patients should be mobilized along with compression therapy within the tolerance limits of pain. Compression therapy may be started with short-stretch bandages followed by support stockings if tolerated by the patient.[1],[5]


  Conclusions Top


SVT, though seemingly benign, has the potential for serious complications. It is imperative to promote awareness of this condition to be able to start accurate and adequate treatment. Prospective studies and registries are the way forward in our country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Nasr H, Scriven JM. Superficial thrombophlebitis (superficial venous thrombosis). BMJ 2015;350:h2039.  Back to cited text no. 1
    
2.
van Langevelde K, Lijfering WM, Rosendaal FR, Cannegieter SC. Increased risk of venous thrombosis in persons with clinically diagnosed superficial vein thrombosis: Results from the MEGA study. Blood 2011;118:4239-41.  Back to cited text no. 2
    
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Wasan S. Superficial thrombophlebitis and its management. In: Sidawy AN, Perler BA, editors. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Elsevier; Philadelphia, PA; 2018.  Back to cited text no. 3
    
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Kalodiki E, Stvrtinova V, Allegra C, Andreozzi G, Antignani PL, Avram R, et al. Superficial vein thrombosis: A consensus statement. Int Angiol 2012;31:203-16.  Back to cited text no. 5
    
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Décousus H, Bertoletti L, Frappé P, Becker F, Jaouhari AE, Mismetti P, et al. Recent findings in the epidemiology, diagnosis and treatment of superficial-vein thrombosis. Thromb Res 2011;127 Suppl 3:S81-5.  Back to cited text no. 8
    
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Decousus H, Quéré I, Presles E, Becker F, Barrellier MT, Chanut M, et al. Superficial venous thrombosis and venous thromboembolism: A large, prospective epidemiologic study. Ann Intern Med 2010;152:218-24.  Back to cited text no. 9
    
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Rosendaal FR. Thrombosis in the young: Epidemiology and risk factors. A focus on venous thrombosis. Thromb Haemost 1997;78:1-6.  Back to cited text no. 10
    
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Frappé P, Buchmuller-Cordier A, Bertoletti L, Bonithon-Kopp C, Couzan S, Lafond P, et al. Annual diagnosis rate of superficial vein thrombosis of the lower limbs: The STEPH community-based study. J Thromb Haemost 2014;12:831-8.  Back to cited text no. 12
    
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Aguilar C, del Villar V. D-dimer is not useful for the diagnosis of isolated superficial venous thrombosis. Am J Med 2005;118:1417.  Back to cited text no. 13
    
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Galanaud JP, Sevestre MA, Pernod G, Kahn SR, Genty C, Terrisse H, et al. Long-term risk of venous thromboembolism recurrence after isolated superficial vein thrombosis. J Thromb Haemost 2017;15:1123-31.  Back to cited text no. 14
    
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Galanaud JP, Genty C, Sevestre MA, Brisot D, Lausecker M, Gillet JL, et al. Predictive factors for concurrent deep-vein thrombosis and symptomatic venous thromboembolic recurrence in case of superficial venous thrombosis. The OPTIMEV study. Thromb Haemost 2011;105:31-9.  Back to cited text no. 15
    
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NICE. Varicose Veins: Diagnosis and Management – Guidance and Guidelines NICE. Available from: https://www.nice.org.uk/guidance/cg168. [Last accessed on 2018 Oct 16].  Back to cited text no. 16
    
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Binder B, Lackner HK, Salmhofer W, Kroemer S, Custovic J, Hofmann-Wellenhof R. Association between superficial vein thrombosis and deep vein thrombosis of the lower extremities. Arch Dermatol 2009;145:753-7.  Back to cited text no. 17
    
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Martinelli I, Cattaneo M, Taioli E, De Stefano V, Chiusolo P, Mannucci PM. Genetic risk factors for superficial vein thrombosis. Thromb Haemost 1999;82:1215-7.  Back to cited text no. 18
    
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Mouton WG, Kienle Y, Muggli B, Naef M, Wagner HE. Tumors associated with superficial thrombophlebitis. Vasa 2009;38:167-70.  Back to cited text no. 19
    
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Gillet JL, Ffrench P, Hanss M, Allaert FA, Chleir F. Predictive value of D-dimer assay in superficial thrombophlebitis of the lower limbs. J Mal Vasc 2007;32:90-5.  Back to cited text no. 20
    
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Sartori M, Migliaccio L, Favaretto E, Cini M, Legnani C, Palareti G, et al. D-dimer for the diagnosis of upper extremity deep and superficial venous thrombosis. Thromb Res 2015;135:673-8.  Back to cited text no. 21
    
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Palareti G, Cosmi B, Legnani C, Tosetto A, Brusi C, Iorio A, et al. D-dimer testing to determine the duration of anticoagulation therapy. N Engl J Med 2006;355:1780-9.  Back to cited text no. 22
    
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Eichinger S, Minar E, Bialonczyk C, Hirschl M, Quehenberger P, Schneider B, et al. D-dimer levels and risk of recurrent venous thromboembolism. JAMA 2003;290:1071-4.  Back to cited text no. 23
    
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Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e419S-96S.  Back to cited text no. 24
    
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Decousus H, Prandoni P, Mismetti P, Bauersachs RM, Boda Z, Brenner B, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med 2010;363:1222-32.  Back to cited text no. 25
    
26.
Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2018;2:CD004982.  Back to cited text no. 26
    
27.
Beyer-Westendorf J, Schellong SM, Gerlach H, Rabe E, Weitz JI, Jersemann K, et al. Prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: The open-label, randomised, non-inferiority SURPRISE phase 3b trial. Lancet Haematol 2017;4:e105-13.  Back to cited text no. 27
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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