Thrombophlebitis is a condition in which a blood clot (a thrombus) has formed inside a vein, causing the surrounding veins to become inflamed (phlebitis). There are two types of thrombophlebitis: superficial vein thrombosis (SVT) and deep vein thrombosis (DVT). SVT imposes less medical risk, although it may be a warning sign of the more serious DVT, especially if it occurs in the long veins of the extremities. However, DVT can be life–threatening if the blood clot or pieces of the blood clot break loose and travel to another part of the body, lodging in another blood vessel and causing an embolism. If pieces of the clot lodge in an artery of the lungs, it could cause a potentially fatal pulmonary embolism.
A number of factors can contribute to the formation of blood clots. These factors include disease, injury or surgery. People at higher risk for forming blood clots include those who smoke, are obese or who are pregnant. Symptoms of thrombophlebitis include swelling, tenderness and throbbing. Anticoagulant medications are generally the first line of treatment for the condition. If the potential danger persists despite treatment (e.g., the clot will not dissolve), then more invasive procedures may be necessary.
About thrombophlebitis
Thrombophlebitis is a type of peripheral venous disorder in which an obstructing blood clot (a thrombus) has formed, causing the surrounding vein to become inflamed (phlebitis). There are two types of thrombophlebitis: superficial vein thrombosis (SVT) and deep vein thrombosis (DVT).
SVT is the formation of an obstructing blood clot in the superficial veins located near the surface of the skin. SVT is often painful, but poses no serious medical threat because these blood clots rarely break off and travel through the bloodstream. SVT may, however, be a sign that DVT exists somewhere else in the leg. SVT is often accompanied by tiny blood clots lining the interior of the veins.
DVT is the formation of an obstructing blood clot in the deep veins embedded in the muscles, usually in the lower leg and sometimes in the lower abdomen or groin. It is important to note that a diagnosis of a blood clot in the superficial femoral vein is actually part of the DVT spectrum and should be treated aggressively. Studies have shown that many labs and treating physicians confuse this diagnosis with that of the less-dangerous superficial thrombophlebitis, despite the fact that the superficial femoral vein is part of the deep venous system.
While DVT may cause no symptoms, it commonly causes permanent damage to the vein. It also carries a very high risk (about 50 percent) of either the whole blood clot or a piece of the blood clot breaking off and traveling through the bloodstream. If the traveling material lodges in one of the arteries of the lungs, then a potentially fatal pulmonary embolism could result. Rarely, the embolism may cause a stroke if it travels into the heart and passes through a hole between the right side of the heart and left side of the heart (atrial septal defect or ventricular septal defect). In many cases, an embolism is the first indication of DVT.
Risk factors and causes for thrombophlebitis
The majority of people who are diagnosed with either SVT or DVT have at least one risk factor for blood clots. In many cases, two or more risk factors are present. These risk factors include:
Surgery, particularly orthopedic, major vascular and neurosurgery
Traumatic injury
Pregnancy
Advanced age
Oral contraceptive use or hormone replacement therapy (HRT)
Recent stroke
Infection of a blood vessel
Lupus erythematosus
Inflammatory bowel disease
Certain types of cancer
Prolonged inactivity (e.g., lengthy bed rest, long hours at the computer)
Intravenous (I.V.) line that is causing irritation
Intravenous drug use
Hyperhomocysteinemia
Congenital hypercoagulable syndromes
History of smoking
Obesity(body mass index of 30 or greater)
Type 2 diabetes
Heart failure
History of varicose veins
Previous episodes of thrombophlebitis
Use of a central venous catheter
Inherited coagulation disorders: Protein C and S deficiency
Some studies have also identified a risk factor that might contribute to the so–called “economy class syndrome.” This is thrombophlebitis that results from sitting in a tight space over the course of a long airplane flight. The link between thrombophlebitis and airline travel is disputed, and not all studies agree on the risk. However, it is recommended that all passengers try to move around as often as possible – taking a walk up and down the aisle, or doing some leg stretches while seated. Loosening or removing one’s shoes is also advised. Planned rest stops during a long car ride are beneficial as well.
Finally, there is a hereditary element to blood clots. Inherited conditions can include deficiencies in certain blood components that normally help dissolve clots, defective blood clotting factors that are unable to activate the body’s clot dissolving system and defective enzymes that occur due to vitamin deficiencies (e.g., vitamin B–12 or folic acid). Inherited thrombophlebitis usually appears in people under 50 and is often recurrent.
Signs and symptoms of thrombophlebitis
The signs and symptoms of thrombophlebitis depend on the type. Deep vein thrombosis (DVT), which occurs in the deep muscles of the legs, frequently has no symptoms, and patients may only become aware of a problem when an embolism develops. Depending upon where the embolism occurs, symptoms of an embolism can include:
Rapid heart rate
Shortness of breath
Sharp chest pain
Blood–tinged coughing
About half of the time, patients with DVT will experience symptoms directly related to the DVT. These include:
Swelling and tenderness, which may or may not occur in the affected area
Inflammation
Discoloration in the skin
A throbbing or burning sensation
Pain during movement
Fever
Increased heart rate
By contrast, patients with superficial vein thrombosis (SVT) more often have signs and symptoms, although the condition is frequently considered benign. Signs and symptoms of SVT generally include:
Swelling and tenderness in the affected area
Inflamed veins that are visible through the skin or feel hard to the touch
A throbbing or burning sensation just below the skin surface.
Diagnosis methods for thrombophlebitis
Diagnosis of thrombosis begins with a complete medical history and physical examination. A number of tests can then be used to confirm the diagnosis. Most commonly, a physician will order an ultrasound – an imaging technology that uses sound waves to produce images of the shape and outline of various tissues and organs in the body, such as the veins. This test is about 95 percent accurate.
Although SVT is generally considered benign, many centers recommend that these patients also have ultrasound to rule out DVT, which can be a very serious condition. This is especially true among patients who have additional risk factors for DVT or have SVT that is located above the knee.
Alternatively, a physician may order one of the following:
Venogram. A diagnostic test in which a dye (contrast medium) is injected into a vein in the affected area prior to an x-ray so that the resulting film will reveal the shape, size and composition of the vein, as well as any obstructions.
Plethysmogram. A noninvasive test used to measure the blood flow in the veins of the arms or legs in order to detect and assess the presence of any blockages. During this test, the patient lies still while a thigh cuff is inflated to impede venous blood flow. After the cuff is deflated, blood flow from the lower extremity is measured. Although this test has about a 90 percent success rate, it has inherent drawbacks that limit its usefulness, especially considering the effectiveness of ultrasound. However, this test is, in some cases, preferred for cases of recurrent DVT.
Magnetic resonance imaging (MRI). A noninvasive test that uses magnetic fields to produce high–resolution cross–sectional or three–dimensional images of the targeted area. While this test has been shown to be highly accurate, it is expensive and not included as part of the usual testing armamentarium for DVT.
Blood test. This test looks for the presence of certain clot–dissolving substances that usually are associated with thrombophlebitis. A blood test, however, is not considered conclusive on its own.
Treatment and prevention of thrombophlebitis
Blood clots will usually dissolve through the normal healing process, so treatments are often aimed at reducing the symptoms and preventing the clot from becoming an embolism. In the case of superficial vein thrombosis (SVT), treatment is aimed at relieving any symptoms and preventing the condition from progressing to deep vein thrombosis (DVT). Thus, the nature of treatment and follow-up testing will likely depend on the exact location of the phlebitis. Some locations with SVT are more likely to progress to DVT than others. SVT can usually be treated with a combination of the following:
Elevation and bandaging of the affected area (to reduce swelling)
NSAIDs (non–steroidal anti–inflammatory drugs) (to reduce inflammation of the vein)
Compression stockings
Anticoagulants. In more serious cases, with a higher risk of progressing to DVT, may be treated with drugs that help prevent the formation of new blood clots. Usually, an anticoagulant is first administered intravenously (e.g., heparain) and then followed up with more anticoagulant drugs taken by mouth (e.g., warfarin). These drugs typically require very close monitoring because their dosing is very sensitive. As a result, frequent blood test will likely be required.
Vein stripping (used only after other treatments have failed). Segments of the damaged veins are tied off, cut and then surgically removed through a series of small incisions.
DVT generally requires more aggressive treatment that may include a variety of medical and interventional options. The goal of therapy with DVT is to prevent the clot from growing larger and reduce the risk the clot will break off and cause a pulmonary embolism. Medications that may be prescribed to prevent this include:
Clot busters. Whereas anticoagulants prevent clotting, clot busters can actually dissolve a blood clot. These medications are administered through an intravenous (I.V.) line. After two days, the treatment is followed by an anticoagulant medication to prevent the formation of additional blood clots. A more recent approach for infusion therapy has been the use of a catheter instead of an I.V. line for more direct infusion (right into the clot) of higher concentrations of enzymes with fewer side effects.
Antibiotics. May be given to treat an infection if one is present.
Alternatively, patients may be recommended for a vena caval filter. This device is a small, basket-type filter that is implanted into the inferior vena cava vein, which drains blood from the lower portion of the body into the heart. It is implanted during a catheter-based intervention, in which a physician guides a catheter into the vein and implants the filter. This procedure is used among patients who cannot tolerate anticoagulant therapy, or after there has been a complication resulting from anticoagulant therapy. The basket is designed to strain blood clots from circulation before they can reach the heart.
Regular exercise is an excellent strategy for preventing thrombosis because it promotes strong muscles and good circulation. Because there is always a small risk of thrombophlebitis associated with surgery, patients should perform calf and leg exercise before surgery and resume activity as soon as possible after surgery. For those confined to a bed or chair, regular stretching and leg movement are vital, especially for individuals who sit at a desk all day or are traveling on long trips. Individuals should avoid smoking, sitting with crossed legs and wearing tight garments below the waist such as garters or knee–high hosiery. Maintaining a healthy weight is equally important.
Questions for your doctor on thrombophlebitis
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. You may wish to ask your doctor the following questions about thrombophlebitis:
Do I have a high risk for developing thrombophlebitis?
What are my treatment options?
Will I need surgery?
Are there any changes I can make now to improve my condition immediately?
What does the latest data state about flying with this condition?
I drive at least one hour each way to and from work; does this worsen my condition?
