What is thrombophlebitis
The term thrombophlebitis indicates a generic inflammation of the wall of a vein, associated with the formation of a blood clot inside it (called thrombus). The thrombus can clog the inner lumen of the blood vessel and slow the circulation; per quesro, the vein affected by thrombophlebitis can become edematous, irritated and lasts on palpation.
The disorder is common, with higher incidence rates among women and the elderly. Thrombophlebitis can be managed with different treatments, which include surgical approaches and drugs, useful for relieving pain and reducing the risk of emboli. The condition, if continued over time, can cause chronic venous insufficiency, with edema, pain, stasis skin pigmentation and ulcers.
Note. Thrombophlebitis is an inflammatory process, associated with the thrombosis of the vessel itself. A thrombus arises following the adhesion of the platelets with the vessel wall (normally smooth, it may present roughness or plaques that favor its formation). The mass gradually increases its size, projecting into the vessel lumen and reducing its diameter. In some cases, the vessel may be completely occluded by the thrombus; at other times, a large piece of thrombus can be detached, causing the formation of a dangerous embolus, that is, a blood clot that enters the circulation. An embolus can travel in the blood and be completely cleaved from the plasmin or end up enclosing a smaller caliber vessel. This second occurrence may result in the blockage of circulation in downstream districts and tissue ischemia, up to necrosis.
Signs and symptoms
To learn more: Symptoms Thrombophlebitis
Signs and symptoms often associated with thrombophlebitis include:
- Pain along the course of the vein;
- Local swelling (edema);
- Swelling of the affected limb;
- Redness (erythema) and inflammation of the skin (not always present).
Superficial and deep venous thrombophlebitis
Superficial thrombophlebitis
- It affects the veins near the surface of the skin;
- It manifests as redness and swelling of the skin, associated with localized edema and pain. At clinical palpation, the vein can be detected, as it takes on characteristics similar to a hard, linear and painful bead on palpation.
- It can resolve spontaneously in a week or two.
- In rare cases, thrombophlebitis can recur and cause great pain and immobility. Blocked veins may be affected by infections (septic thrombophlebitis) and tissue damage may occur due to impaired healthy circulation. In addition, complications can arise due to the extension of the condition to the deep veins, which can lead to deep vein thrombosis (DVT).
Deep venous thrombophlebitis
- It affects the larger and deeper veins, located far from the surface of the skin (in practice, inflammation causes deep vein thrombosis);
- Deep venous thrombophlebitis has characteristics of greater severity: it presents with generalized edema, heat and redness in the area involved, distension of superficial veins, bluish color of the skin or extremities (cyanosis), and rarely, fever and chills; walking becomes impossible because of pain.
- At first, it may produce less pronounced symptoms (half of all cases are asymptomatic), but it carries the risk of pulmonary embolism (when the clot detaches from the site of origin and travels towards the lung), and chronic venous insufficiency (altered blood outflow through the veins), resulting in dermatitis, skin discoloration and swelling.
Causes
Several causes can contribute to the onset of thrombophlebitis:
- Reduction of blood velocity in the veins: it can derive from prolonged immobility. Venous blood stasis is common both in bed-ridden hospitalized patients (for any chronic disease, heart failure, stroke and trauma or following a surgical operation), and in healthy people who maintain a long sitting or lying position ( for example, air travel).
- Damage to venous endothelium: lesions to the walls of the blood vessel can be caused by trauma, infectious agents, intravenous catheters or needles, injection of irritants or chemotherapeutic agents.
- Conditions that increase the tendency of the blood to coagulate, such as, for example, a congenital or acquired deficiency of coagulation factors (eg hemophilia).
- Pregnancy and the presence of varicose veins are associated with a higher risk of superficial thrombophlebitis. Some tumors, on the other hand, are associated with deep vein thrombophlebitis. Migrant thrombophlebitis (or sign of Trousseau's malignancy) is a paraneoplastic syndrome, characterized by recurrent thrombosis in the veins in various parts of the body.
Risk factors
Tomboflebite has causes attributable to three main predisposing alterations, described in the Virchow triad:
- Damage to the blood vessel wall (due to trauma, infection or inflammation);
- Venous stasis or blood flow turbulence;
- Hypercoagulability of blood (or thrombophilia).
The risk of thrombophlebitis increases in the event of:
- Inactivity for a long period of time (example: keeping a seated position in the car or on an airplane, or lying down after a surgery or an injury);
- Pacemaker or catheter in a central vein, for the treatment of a medical condition: it can irritate the blood vessel wall and slow blood flow;
- Intravenous infusion: superficial thrombophlebitis can occur at sites of infusion or trauma in the region of the arm or neck, especially if an irritant has been infused);
- Changes in blood coagulation:
- Personal or family history of thrombophilia;
- Use of estrogen hormones (oral contraceptives or hormone replacement therapy);
- Some malignant neoplasms such as, for example, pancreatic cancer, associated with hypercoagulability;
- Pregnancy (during gestation and for about 6 weeks after birth, the pressure in the veins of the pelvis and legs increases);
- Diseases associated with vasculitis, such as Buerger's disease and nodular polyarthritis.
Other risk factors include:
- Age over 60 years;
- Obesity;
- Smoke;
- Intravenous drug abuse.
Complications
If thrombophlebitis is superficial, complications are rare. However, if the tombo occurs in a deep vein the risk of developing a serious medical condition is greater.
Thrombophlebitis complications may include:
- Pulmonary embolism . If a fragment of the thrombus detaches, it can pass through the heart and get stuck in a small capillary of the lungs, causing the circulatory block (pulmonary embolism). Pulmonary embolism is a potentially life-threatening situation.
- Acute myocardial infarction or stroke . If a fragment of the thrombus travels through the bloodstream towards the coronary arteries or the brain, it can cause a heart attack (acute myocardial infarction) or a stroke. This complication can occur especially in patients with certain types of congenital heart defects, such as a patent foramen ovale (PFO).
Other consequences of thrombophlebitis may include:
- Stasis pigmentation: venous insufficiency and chronic swelling, especially in cases of repeated thrombophlebitis, lead to a reduction in the oxygen supply to the skin. This event can lead to dehydration and increased pigmentation of the skin, which takes on a brownish color. In some cases, eczematous and itchy patches appear spontaneously or due to minimal traumas, up to the formation of skin ulcers (especially around the ankle);
- Infectious phlebitis is possible due to the presence of a septic process at the level of the limb or venous obstruction, and can lead to metastatic abscesses and septicemia.
Diagnosis
Diagnosis is based on the patient's history and physical examination of the affected area, which allows to differentiate superficial thrombophlebitis from deep venous thrombophlebitis. Superficial thrombophlebitis is diagnosed thanks to the symptoms and the relief of a superficial venous cord.
The set of the clinical picture, including the presence of risk factors and specific findings at the level of the affected limb, allow the doctor to hypothesize a diagnosis of deep vein thrombophlebitis, which will then be confirmed by further investigations. If the condition is repeated often or there is the possibility of complications, the doctor may perform other tests, such as: blood tests, venography and echo-Doppler.
Treatment
Thrombophlebitis is generally a self-limiting benign disease. However, some cases may prove difficult to treat. If the condition affects a vein just below the skin, the doctor may recommend a local therapy based on the application of specific ointments (based on hesperidin, ruscogenin, rutin, asiaticoside etc.), on the elevation of the affected area, on the use of an elastic support (stockings or bandage) and possibly on the use of anti-inflammatories. In some cases, heparin treatment may be associated, to help reduce edema, pain and the chances of deep vein thrombosis and embolism. The condition usually does not require hospitalization and improves within a week or two.
In severe cases, people with thrombophlebitis may need to be treated with drugs to reduce swelling or treat infections. In the case of deep venous thrombophlebitis, the goal of therapy is to prevent pulmonary embolism and chronic venous insufficiency. Doctors can prevent the formation of emboli and thrombi by administering drugs that reduce platelet activity or dissolve blood clots present. The anticoagulant drugs include heparin, which inactivates thrombin, and some coumarin derivatives, which depress the synthesis of several coagulation factors. Emergency conditions, including pulmonary embolism with acute arrest of coronary circulation, can be treated with thrombus substances such as streptokinase, urokinase or tissue plasminogen activator (t-PA).
To learn more: Thrombophlebitis drugs
General measures
- Once the edema has subsided, elastic supports or graduated compression stockings may be prescribed to help the circulation of the lower limbs. During walking, an elastic-compression bandage of the limb helps to reduce swelling and the possibility of complications of deep vein thrombosis: edema, pain, skin pigmentation and stasis ulcers.
- Physical activity reduces pain and the risk of deep vein thrombosis (DVT). The patient should also be checked frequently to make sure that the thrombus formation does not progress.
- Only in cases where the pain is very severe, bed rest is required with the elevation of the limbs by a few centimeters, compressed using special devices. In patients with reduced mobility, prophylaxis for deep vein thrombosis should be established.
- For superficial thrombophlebitis, topical analgesia with locally applied non-steroidal creams and anti-inflammatories is generally effective in symptom control.
- Application of wet and hot compresses, although it is known that their effectiveness is limited.
drugs
Thrombophlebitis treatment may include the following drugs:
- Analgesics, to reduce pain;
- Anticoagulants, for example warfarin (coumarin anticoagulant drug) or heparin, prevent the formation of new thrombus;
- Thrombolytics, to dissolve an existing clot, such as intravenous streptokinase.
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to reduce pain and inflammation.
Antibiotics are needed only if there is evidence of specific infections.
Surgical approach
- For the treatment of persistent thrombophlebitis, the doctor may recommend surgery to bypass the vein. An angioplasty, with insertion of a stent, allows to keep the segment of the blood vessel affected by the inflammatory process. Surgery is also necessary to treat the occlusion of a vein in the pelvis or abdomen.
- In some cases, especially if "blood thinners" cannot be taken, the doctor can implant a small filter in the vena cava in the abdomen, to prevent the breaking of the thrombi to cause embolic complications. Generally, the filter remains permanently implanted.
- Patients with septic thrombophlebitis require urgent surgical excision, to stop the spread of infection. This is done by making a direct cut above the vein and removing the infected segment and any surrounding necrotic tissue. This procedure can also be applied to patients with recurrent superficial thrombophlebitis who do not respond to other treatments.
Prognosis
The prognosis is generally good, but the process can persist for 3-4 weeks or more. Thrombophlebitis is usually benign, although it can cause a lethal pulmonary embolism or chronic venous insufficiency. If it occurs in association with varicose veins, there is a high risk of relapse, unless the segment is surgically removed. An isolated episode of thrombophlebitis may require approximately 2 months of therapy, while a patient with pulmonary embolism and persistent risk factors may need a more prolonged treatment plan.
