Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 250-253

Superficial-vein thrombosis of the lower limb: A pathology that is not always benign


Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Oujda, Mohammed 1st University, Oujda, Morocco

Date of Submission12-Jan-2020
Date of Decision26-Jan-2020
Date of Acceptance26-Feb-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Abdellah Rezziki
Department of Vascular Surgery, Faculty of Medicine and Pharmacy of Oujda, Mohammed 1st University, Oujda
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_5_20

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  Abstract 


Objectives: The value of our observations is to take stock of the interest of the medical and surgical management of superficial vein thrombosis. Case Report: We report three patients with severe superficial vein thrombosis whose symptoms were painful induration along the course of the superficial veins of the lower limb. The diagnosis was confirmed by venous Doppler, follow-up was marked by the occurrence of thromboembolic complications (pulmonary embolism) in one patient. Results: All patients received emergency treatment-anticoagulation for a week with relay by Vitamin K antagonists, surgery as an emergency consisted of ligation of the saphenofemoral junction (SFJ) under local anesthesia in one patient (Case 2). One of the patients had a pulmonary embolism 3 days later, and this patient did not receive surgical ligation. The third patient has progressed well on anticoagulant therapy. Discussion: Superficial vein thrombosis of the lower limbs has long been considered as benign with the natural course often leading to resolution of the thrombus and in rare cases complications which can affect the prognosis of the patient. Anticoagulation should be started urgently especially before extensive thrombosis and surgical ligation of the SFJ considered to prevent thrombus propagation. Conclusion: Superficial vein thrombosis is often considered to have a benign course once diagnosed. Experience from our short series suggests that the management should be more aggressive and robust with anticoagulation and consideration of ligation of the SFJ where thrombosis is extensive and reduce the dreaded complication of a pulmonary embolism. Therapeutic recommendations concerning this disease have a relatively weak level of certitude as no treatment has been proved of benefit. We thought interesting to talk through observational clinical cases and expose our personal attitude to a serious superficial vein thrombosis.

Keywords: Ligation of the saphenofemoral junction, superficial venous thrombosis, thromboembolism


How to cite this article:
Rezziki A, Hussam A, Oussama A, Taha A, Adnane B, Omar E. Superficial-vein thrombosis of the lower limb: A pathology that is not always benign. Indian J Vasc Endovasc Surg 2020;7:250-3

How to cite this URL:
Rezziki A, Hussam A, Oussama A, Taha A, Adnane B, Omar E. Superficial-vein thrombosis of the lower limb: A pathology that is not always benign. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Oct 30];7:250-3. Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/250/294908




  Introduction Top


Superficial venous thrombosis (SVT) is a common condition, very often considered to be mild compared to deep vein thrombosis (DVT). Few studies have been interested in this pathology and the data in the literature highlighting the seriousness of this pathology remain relatively rare.[1] On the clinical level, and unlike DVT where the signs prove to be irrelevant, the diagnosis of SVT is clinical, made on a finding of a hard subcutaneous venous segment which is tender and inflamed adjacent to, or at the site of a previously healthy or varicose vein. The risk of pulmonary embolism or serious underlying conditions justifies specific management.[1],[2] A venous Doppler ultrasound allows the study of thrombosis and provides a lot of information on the extension of thrombosis in relation to the saphenofemoral and saphenopopliteal junctions.


  Clinical Cases Top


Case 1

A 48-year-old female, on follow-up for bilateral varicose veins of the two lower limbs, taking oral contraception for a long period, presented with a recent history of pelvis trauma requiring bed rest for 2 weeks. She was admitted to the emergency room for acute pain in both lower limbs, of 2 days' duration. Examination revealed inflammatory cords following the course of the left and right internal great saphenous veins (GSVs), that were inflamed and painful to palpation [Figure 1] and [Figure 2].
Figure 1: Photograph of a patient with a superficial vein thrombosis of bilateral viridans group Streptococcus, note the inflammatory red lead into the path of saphenous veins

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Figure 2: Focus on the path of the viridans group Streptococcus

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An emergency venous duplex was performed which that the GSV was thrombosed up to the saphenofemoral junction (SFJ) bilaterally. Anticaogaulation using low molecular weight heparin (LMWH) enoxaparin sodium 1 mg/kg per subcutaneous injections every 12 h. The patient presented 3 days after her admission chest pain with dyspnea; a computed tomography pulmonary angiograph was performed showing bilateral segmental and subsegmental pulmonary embolism [Figure 3] and [Figure 4]. The patient was resuscitated following 5 days and she was discharged on acenocoumarol 4 mg/day with international normalized ratio (INR) was at 2, 3.
Figure 3: Chest angio-computed tomography objectifying a pulmonary embolus truncal left bronchus (arrow)

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Figure 4: Chest angio-computed tomography objectifying a pulmonary embolus truncal (arrow)

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Case 2

A 50-year-old patient admitted to the visceral upper gastrointestinal surgery department for posttraumatic splenectomy, a week after his discharge the patient presented for SVT on varicose internal saphenous vein with infection and collection in the venous path and fistulization to the skin. An emergency venous Doppler ultrasound objectified a thrombosis of the internal saphenous vein extended to the veinous cross [Figure 5]; an emergency crossectomy was performed with drainage and drying up of the infection. The patient was hospitalized for 5 days and put on a curative dose of anticoagulant therapy by LMWH enoxaparin 1 mg/kg twice a day for 8 days, with relay by VKAs (Acenocoumarol 2 mg/day, INR 2–3), with a follow-up of 6 months without detectable thromboembolic complications.
Figure 5: Venous Doppler echo of the left leg objectifying complete thrombosis of the trunk of the viridans group Streptococcus and the extension of superficial venous thrombosis to the saphenofemoral junction

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Case 3

A 56-year-old patient with no notable pathological history, in particular no clinically detectable chronic venous insufficiency, admitted to the emergency room for a snake bite, after conditioning in the intensive care unit, the patient presented with induration in the course of the GSV [Figure 6]. On venous Doppler ultrasonography, a SVT is objectified, concerning the GSV in its leg portion; the patient was put on enoxaparin 1 mg/kg twice a day 1 week, with relay by VKAs 2 mg/day with INR 2–3. The follow-up has been favorable.
Figure 6: Photograph of the lower limb with retromalleolar bites points and superficial vein thrombosis of the viridans group Streptococcus

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  Results Top


Our study included two women and a man, with an average age of 51.33 years and extremes between 48 and 56 years. The history of varicose veins of the lower limb was present in two patients. Intake of oral contraception was found in one patient.

The consultation time after the onset of pain was from few hours to 2 days.

In the first patient, the SVT was bilateral and spread over the entire path of the internal saphenous vein with intense inflammatory signs including pain, redness and induration, in the second observation, the clinical manifestations were identical with in addition a sign of severity which was suppuration and fistulization to the skin.

Doppler ultrasound allowed for all of our patients to confirm the diagnosis of SVT, and to eliminate an associated DVT. Venous Doppler ultrasound also allowed us to study the extension of the thrombosis which reached the SFJ in the first two patients while it was located in the leg portion of the GSV in the third patient.

All of our patients received urgent anticoagulant treatment based on LMWH (enoxaparin sodium 1 mg/kg twice a day) for 1 week, relayed by VKAs with an INR objective between 2 and 3.

The emergency surgical treatment consisted of a crossectomy under local anesthesia was performed in one patient (observation 2).

A case of pulmonary embolism was observed after 3 days of evolution; this patient did not benefit from a surgical crossectomy.


  Discussion Top


SVT is a common condition but, long considered benign and requiring only symptomatic treatment.[1],[2],[3] Natural evolution is healing but is sometimes accompanied with complications that can involve the patient's vital prognosis.

The incidence of SVT in the general population is estimated between 3%–11%.[4] The average age of presentation is 60 years. This pathology occurs in women more than men.[4],[5] No current study has taken stock of the real prevalence of this pathology in the general population since the symptoms are not always as worrying for patients and do not always require the use of treating physicians.[1],[5]

The risk factors for SVT are dominated by the presence of varicose veins of the lower limbs (80%).[4],[6] The involvement of the internal saphenous vein is the most described with a frequency of 60%–80% of cases. The external saphenous vein is involved in 10%–20% of cases.[1],[4]

The other risk factors are roughly the same as for thromboembolic disease, including prolonged immobilization, long travel, trauma, cancer or gynecological surgery, hormone use (oral contraception), pregnancy, and thrombophilia. The presence of SVT apart from usual risk factors makes suspected underlying cancer even in the absence of clinical signs.[4],[7],[8]

SVT is closely linked to thromboembolic disease (DVT, PE) and is sometimes only the tip of the iceberg.[1]

According to the post study (that included 844 patients with SVT), 25% had concomitant DVT, 10% of the rest (600 patients) had a thromboembolic complication within 3 months.[3],[6],[7],[9]

The predictive factors for thromboembolic complications found are the male sex, the history of thromboembolic diseases, and the presence of a previous chronic venous insufficiency.[9] A distance <3 cm on Doppler ultrasound between thrombosis and the saphenofemoral or saphenopopliteal junction is a factor that has prompted several studies without being statistically significant.[3],[6],[9]

Clinically, SVT can manifest itself by an indurated red inflammatory cord, painful spontaneously and at the slightest palpation, on a path of a superficial vein most often the internal saphenous vein.[1],[3]

The presence of a concomitant DVT and the risk of thrombus migration either by the saphenofemoral or saphenopopliteal junction or even by the perforating veins implies the realization of a Doppler ultrasound which is not very contributing to the positive diagnosis but which gives information on the localization of the thrombus and the state of the deep venous system.[3],[10] In our observation, all our patients benefited from an emergency venous Doppler ultrasound.

The treatment of isolated SVT of the lower limbs has not been fully established: The recommendations of the experts are of low level of evidence, and therefore the treatment varies widely from one physician to another.[1],[3] The various therapeutic measures which have been proposed include mobilization, compression bands, nonsteroidal anti-inflammatory drugs (NSAIDs) or analgesics by local or general route, anticoagulation by unfractionated heparin, LMWH, or Vitamin K antagonists or surgery (crossectomy).

Experts at the American College of Chest Physicians recommend anticoagulant-based medical treatment rather than surgical treatment.[3],[7]

For AFSAPS:[11] NSAIDs administered by the general route are not recommended as firstline treatment (and have only an analgesic effect locally) (Grade C).

The prescription of a venous compression, preferably by bandage (in elastic or inelastic compression according to the clinic and the practitioner's preferences), is recommended in the acute phase of a DVT of a limb in the absence of contraindication (professional agreement).

SVTs extended to the internal saphenous-femoral vein junction may be part of an anticoagulant treatment with a curative dose of venous thromboembolism or surgical treatment (professional agreement).

If an anticoagulant treatment is started, it is suggested to treat 7–30 days (Professional agreement).

Surgical treatment, in particular a crossectomy of the GSV or small saphenous vein, is only discussed when the thrombosis is close to the sphenofemoral or saphenopopliteal junction, hence the advantage of performing a venous Doppler ultrasound when an SVT is suspected. It is accepted that from a distance of 3 cm, the risk of thrombus migration is major and there is an indication of an emergency crossectomy.[3],[10],[11] In our first observation, the patient presented with a bilateral and extensive SVT, but she did not benefit from a preventive crossectomy, which is why, most probably, she was complicated by a pulmonary embolism despite a well-conducted anticoagulant treatment.

Complications are dominated by the installation of DVT or pulmonary embolism, with an incidence of 4.6% objectified in a study of 427 patients with SVT in the study carried out by Quenet et al. Predictive factors of thromboembolic complications are male sex, history of ancient thrombosis, and the presence of severe venous insufficiency.[9]


  Conclusion Top


SVT currently remains a poorly understood and poorly managed pathology given the low scientific production devoted to this pathology and given the low level of evidence attributed to the different behaviors to be followed, we thought it worth talking about through observational clinical cases and to expose our personal attitude in front of a serious SVT, and especially to draw attention to the place of preventive surgical crossectomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
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2.
Nasr H, Scriven JM. Superficial thrombophlebitis (superficial venous thrombosis). BMJ 2015;350:h2039.  Back to cited text no. 2
    
3.
Becker F, Quéré I, Guenneguez H, Mismetti P, Leizorovicz A, Decousus H. Superficial venous thrombosis: A pathology to reconsider. Sang Thromb Vaiss 2011;23:280-91.  Back to cited text no. 3
    
4.
Leon L, Giannoukas AD, Dodd D, Chan P, Labropoulos N. Clinical significance of superficial vein thrombosis. Eur J Vasc Endovasc Surg 2005;29:10-7.  Back to cited text no. 4
    
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Karathanos C, Exarchou M, Tsezou A, Kyriakou D, Wittens C, Giannoukas A. Factors associated with the development of superficial vein thrombosis in patients with varicose veins. Thromb Res 2013;132:47-50.  Back to cited text no. 5
    
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Decousus H, Accassat S, El Jaouhari A, Frappé P, Bertoletti L. Données Recent data on the epidemiology, diagnosis and treatment of superficial venous thrombosis of the lower limbs 2012;S334.  Back to cited text no. 6
    
7.
Litzendorf ME, Satiani B. Superficial venous thrombosis: Disease progression and evolving treatment approaches. Vasc Health Risk Manag 2011;7:569-75.  Back to cited text no. 7
    
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Sørensen HT, Sværke C, Farkas DK, Christiansen CF, Pedersen L, Lash TL, et al. Superficial and deep venous thrombosis, pulmonary embolism and subsequent risk of cancer. Eur J Cancer 2012;48:586-93.  Back to cited text no. 8
    
9.
Quenet S, Laporte S, Décousus H, Leizorovicz A, Epinat M, Mismetti P, et al. Factors predictive of venous thrombotic complications in patients with isolated superficial vein thrombosis. J Vasc Surg 2003;38:944-9.  Back to cited text no. 9
    
10.
Leizorovicz A, Becker F, Buchmüller A, Quéré I, Prandoni P, Decousus H, et al. Clinical relevance of symptomatic superficial-vein thrombosis extension: Lessons from the CALISTO study. Blood 2013;122:1724-9.  Back to cited text no. 10
    
11.
Mismetti P, Baud JM, Becker F, Belmahdi F, Blanchard P, Constans J, et al. Guidelines for good clinical practice: Prevention and treatment of venous thromboembolism in medical patients. J Mal Vasc 2010;35:127-36.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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