Superficial thrombophlebitis of the lower limbs from the surgeon’s point of view

Česká verzia

Authors: J. Kalný ¹; L. Tomášková ²; J. Pažin ¹
Authors place of work: Chirurgické oddělení, Nemocnice Sušice o. p. s., přednosta: MUDr. R. Voldřich ¹; Radiodiagnostické oddělení, Nemocnice Sušice o. p. s., přednosta: MUDr. J. Voves ²
Published in the journal: Rozhl. Chir., 2014, roč. 93, č. 5, s. 260-270.
Category: Original articles

Summary

Introduction:
A new consensus on the management of superficial thrombophlebitis (STP) from the Central European Vascular Forum (CEVF) for the diagnosis and treatment of STP recommends anticoagulation treatment either with Fondaparinux 2.5 mg for at least 45 days or with low molecular weight heparin (LMWH) for 4 weeks in patients with thrombosis of GSV/SSV proven by duplex ultrasonography (DUS) and with thrombus length exceeding 5 cm. The dosage and duration of anticoagulation treatment depend on the associated diseases and other risk factors for TVE. Many options for doses an duration of treatment are referred to in the literature. Emergency surgery is not recommended.

The aim of this study is to demonstrate the role of DUS examination in acute ascending thrombophlebitis (ASTP) of the GSV, and demonstrate the efficiency of surgical treatment – crossectomy and phlebectomy of thrombosed GSV/SSV.

Material and methods:
The authors present their clinical experience with DUS diagnosis and surgical treatment of acute ascending thrombophlebitis in GSV/SSV on 66 patients with 68 operations. In two of them bilateral crossectomy was performed. In the diagnosis it is necessary to perform DUS examination after clinical diagnosis of acute thrombophlebitis. It should be done bilaterally, not only in the affected limb. DUS confirms the measure, progression and eventually ascension of the thrombosis on the trunk of the GSV/SSV and perforating veins. Progress of the thrombotic process from the thigh to the SF/SP junction is usually a matter of a few hours. Daily ultrasound assessment should therefore be performed in acute thrombophlebitis, even during anticoagulation therapy. Thrombus near the SF/SP junction is a reason for urgent surgery – crossectomy and phlebectomy.

Results:
66 patients were operated on under general anaesthesia without any complications. A large hematoma in the subinguinal region developed in one patient after surgery. A 50-year-old patient returned with colliquation of the residual varicose vein on the lower leg.

Outpatient incision and evacuation had to be performed 3 weeks after surgery. Anticoagulation therapy with warfarin was started in two patients. The other patients were discharged 4 to 6 days following surgery without any problems. Post-operative anti-coagulation in other patients was not longer than 2 weeks.

Conclusion:
Urgent crossectomy and phlebectomy represent a reliable method of treatment in the management of acute ascending thrombophlebitis of GSV/SSV, guaranteeing prophylaxis of complications, especially in pregnant women with PT in the later phase of pregnancy. Surgical treatment destroys the damaged vein with crossectomy as a potential cause of deep vein thrombosis (DVT), pulmonary embolism (PE) and STP recurrence. After anticoagulation therapy the affected vein remains in situ. It can potentially cause the recurrence of STP, and DVT and PE may develop.

Key words:
superficial thrombophlebitis – diagnosis – surgical treatment– crossectomy – phlebectomy

Zdroje

1. Allegra C. Superficial thrombophlebitis: Thromboembolic risk. Phlebolymphology 2012;20:28.

2. Bergan JJ, Kistner RL. Surgery of acute thrombophlebitis: Overview and commentary atlas of venous surgery. United Kingdom, Saunders (W.B.) Co Ltd, 1992:299.

3. Gillet JL, Perrin M, Cayman R, Cayman R. Thromboembolic recurrence after superficial thrombophlebitis of the lower limbs. Journal of Phlebology 2002;17:103–110.

4. Firt P. Chirurgická léčba povrchních tromboflebitid a podvazy hlubokých žil. Prakt Lek 1978;58:462–463.

5. Herman J, a kol. Chirurgie varixů dolních končetin, Praha, Grada 2003:186.

6. Hirmerová J. Tromboflebitidy – současný doporučený postup. Postgraduální medicína 2013;15:122–127.

7. Imitaz A, Waheed A, Dingui M. Prevention of reversal of deep venous insufficiency by aggresive treatment of superficial venous diseas. American journal of Surgery 2006;191:33–38.

8. Jezovnik MK. Diagnostic algorithm for superficial thrombophlebitis. Phlebolymphology 2013;20:53–54,

9. Kalný J, Frýba V. Ascending thrombophlebitis of the vena saphena magna. Abastracts XXXI angiological days 2006;13.

10. Kalodiki E, Štvrtinová V, Allegro C, et al. Superficial vein thrombosis: A consensus statement. International angiology: A journal of the Internatonal Union of Angiology 2012;31:203–216.

11. Krause U, Kock HJ, Kroger K, et al. Prevetion of deep venous thrombosis associated with superficial trombophlebitis of the leg by early saphenous vein ligation. Vasa 1998;27:34–38.

12. Maeseneer de M, et al. Superficial thrombophlebitis of the lower limb: Practical recommendations for diagnosis and treatment. Acta chir belg 2005;105:145–147.

13. Maeseneer de M. How to treat superficial thrombophlebitis? Phlebolymphology 2010;17:48–49.

14. Marković M, Maksimoviintć Z, Maksimović I, et al. The role of duplex ultrasonography in surgical treatment of acute progressive thrombophlebitis of great saphenous vein. International Angiology: Journal of International Union of Angiology 2011;30: 434–440.

15. Mazuch J, Mištura D, Huĺo E, et al. Thrombophlebitis superficialis varicosa of the lower extremities. Abstracts XXXV angiological days 2010;17.

16. Pitrák V, Nahodil V. Význam podvazu a přerušení vena saphena magna při povrchním žilním zánětu v oblasti stehna. Prakt Lek 1985;65:809–810.

17. Perrin M, Guex JJ, Gillet JL. Traitement chirurgical des thromboses veineuses superficiales des membres inferieurs. Encycl. Med Chir (Elsevier) Techniques chirurgicales. Chirurgie vasculaire Paris 2000;43–165.

18. Ramelet AA, Perrin M, Kern P, Bounameaux H. Superficial thrombophlebitis in flebology. 5th edition. Elsevier, Masson SAS 2008:503–515.

19. Seyček J. Zásady optimální léčby zánětů povrchových žil. Praktická flebologie 2003;12:34–37.

20. Sullivan V, Denk PM, Sonnad S, et al. Ligation versus anticoagulation: Treatment of above involving the deep venous system. J Am Coll Surg 2001;193:556–562.

21. Štvrtinová V. Superficial thrombophlebitis. A new concensus proposal for diagnosis and treatment. Phlebolymphology 2012;20: 28–29.