Ep 33 – Superficial venous thrombosis in primary care

In this episode, Kevin considers the diagnosis and management of superficial venous thrombosis. Lesley is a 64-year-old woman who presents to us with a sore, itchy right leg and no past medical history of note. On examination, she has a tender, hard, erythematous varicose vein extending from her thigh to ankle. What should we do next? Should we be worried about underlying deep vein thrombosis?

Key references discussed in the episode:

• Nasr H, Scriven JM. BMJ. 2015;350:h2039. doi: 10.1136/bmj.h2039.
• NICE. Clinical Knowledge Summary: Superficial vein thrombosis (superficial thrombophlebitis). 2020.
• Di Nisio M, Wichers IM, Middeldorp S. Cochrane Database Syst Rev. 2018;2(2):CD004982. doi: 10.1002/14651858.CD004982.pub6.

Key take-home messages from the episode:

• Superficial venous thrombosis (SVT) is the preferred term to superficial thrombophlebitis because the underlying pathology is that of thrombus formation rather than inflammation or infection.
• SVT shares risk factors with deep vein thrombosis (DVT) and pulmonary embolism (PE).
• If the SVT involves veins near the junction with the deep venous system, the risk of DVT and PE can reach nearly 20%.
• D-dimer is of no value in differentiating SVT from DVT.
• Consider referring all patients with clinical SVT of the lower limb for ultrasound scan.
  • Individuals with below-knee SVT without evidence of DVT can be managed in primary care with non-steroidal anti-inflammatory drugs and compression.
• Individuals with SVT near the sapheno-femoral junction or sapheno-popliteal junction should be considered for surgical ligation or anticoagulation.
  • Also consider anticoagulation if the superficial thrombus is >5 cm in length.
• Antibiotics have no role in the treatment of thrombophlebitis, except in clear cases of infection.