Cardiology >  Thrombophlebitis  

Background 

Thrombophlebitis refers to inflammation of a vein associated with thrombus (blood clot) formation, typically affecting superficial veins. It most commonly occurs in the lower extremities, presenting as a tender, erythematous, cord-like structure along the course of a vein. When it involves deeper veins, it overlaps with deep vein thrombosis (DVT), which carries a higher risk of pulmonary embolism (PE). 

II) Classification/Types 

By Location: 

• • Superficial Thrombophlebitis (STP): Involves superficial veins like the great or small saphenous vein. 

• • Deep Vein Thrombophlebitis (DVT): Involves deep veins (e.g., femoral, popliteal, iliac), typically more dangerous due to embolization risk. 

By Cause: 

• • Septic Thrombophlebitis: Associated with infection (e.g., catheter-related, Lemierre’s syndrome). 

• • Non-septic/Mechanical: Related to trauma, IV catheters, varicose veins, or hypercoagulability. 

By Chronicity: 

• • Acute: Sudden onset pain and swelling, commonly due to recent trauma, surgery, or immobilization. 

• • Chronic: Long-standing post-thrombotic changes in the vein wall; more common in recurrent DVT or venous insufficiency. 

III) Pathophysiology 

Thrombophlebitis arises from Virchow’s Triad: 

• • Venous stasis (e.g., immobility, varicose veins) 

• • Endothelial injury (e.g., IV cannula, trauma) 

• • Hypercoagulability (e.g., malignancy, pregnancy, thrombophilia) 

Inflammation leads to local swelling, pain, and clot formation. In septic cases, bacterial colonization of thrombi leads to systemic infection and septic emboli. 

IV) Epidemiology 

• • Sex: Slight female predominance due to varicose veins and hormonal factors. 

• • Age: Increases with age; peak in 40–60 years. 

• • Geography: Higher incidence in sedentary populations; associated with climate and health behaviors. 

• • Comorbidities: Varicose veins, recent surgery, malignancy, central venous catheter use. 

Etiology

I) Causes 

• • Varicose veins 

• • Intravenous catheters or cannulation 

• • Prolonged immobility or recent travel 

• • Surgery or trauma 

• • Pregnancy and postpartum state 

• • Malignancy (Trousseau’s syndrome) 

• • Hypercoagulable disorders (e.g., Factor V Leiden, antiphospholipid syndrome) 

• • Infection (septic thrombophlebitis) 

II) Risk Factors 

• • Smoking 

• • Hormonal therapy (e.g., OCPs, HRT) 

• • Obesity 

• • Prior history of DVT or thrombophlebitis 

• • Central venous catheters 

• • Inherited thrombophilias 

• • Chronic venous insufficiency 

Clinical Presentation

I) History (Symptoms) 

• • Localized pain or tenderness along a superficial vein 

• • Redness, swelling, and warmth over the affected area 

• • Palpable cord-like vein 

• • Fever and chills (suggestive of septic thrombophlebitis) 

• • Symptoms of PE (dyspnea, chest pain) if thrombus migrates 

II) Physical Exam (Signs) 

Vital Signs: 

• • May be normal 

• • Fever in septic cases 

Local Exam: 

• • Erythematous, warm, tender, cord-like vein 

• • Local edema 

• • No significant distal pitting edema (suggests superficial involvement) 

Systemic Findings: 

• • Signs of sepsis in infectious cases 

• • Homan’s sign rarely positive in STP 

Differential Diagnosis (DDx)

• • Cellulitis 

• • Deep vein thrombosis 

• • Lymphangitis 

• • Erythema nodosum 

• • Lipodermatosclerosis 

• • Muscle strain or hematoma 

Diagnostic Tests

Initial Tests: 

• • Duplex Ultrasonography: 

• • • First-line to confirm presence of thrombus 

• • • Rules out DVT extension 

• • CBC, CRP, ESR: 

• • • May show leukocytosis and elevated markers in septic or extensive inflammation 

• • Blood Cultures: 

• • • If fever or signs of systemic infection 

• • D-dimer: 

• • • May be elevated but non-specific 

• • CT/MRI Venography: 

• • • Rarely needed, used in complex or recurrent cases 

Treatment

I) Medical Management: 

Superficial Thrombophlebitis (without DVT): 

• • • NSAIDs for pain and inflammation 

• • • Warm compresses and elevation 

• • • Compression stockings to support venous return 

• • • Anticoagulation (Fondaparinux, LMWH): 

• • • Indicated if thrombus ≥5 cm, near deep system, or high risk of propagation 

Septic Thrombophlebitis: 

• • Empiric IV antibiotics targeting gram-positive cocci (e.g., vancomycin) 

• • Blood cultures and targeted therapy based on sensitivities 

• • Surgical excision or drainage if abscess or persistent infection 

If DVT confirmed: 

• • Full anticoagulation per DVT guidelines 

II) Interventional/Surgical: 

• • Ligation and excision for recurrent, large varicosities or persistent infection 

• • Catheter removal in catheter-related septic thrombophlebitis 

• • Thrombolysis in select extensive or limb-threatening cases 

Patient Education, Screening, Vaccines

• • Importance of early mobilization post-surgery or travel 

• • Avoid prolonged immobility 

• • Hydration and calf exercises during long travel 

• • Report new leg pain, swelling, or fever immediately 

• • Smoking cessation 

• • Maintain healthy weight and activity 

• • Vaccinations as indicated (especially in hospitalized patients) 

Consults

• • Vascular Surgery: For surgical excision or extensive recurrent thrombophlebitis 

• • Hematology: For evaluation of thrombophilia in recurrent cases 

• • Infectious Disease: For septic thrombophlebitis 

• • Internal Medicine/Primary Care: For comorbidity optimization 

• • Interventional Radiology: If endovascular treatment is required 

Follow-Up

• • Repeat ultrasound in 7–10 days to assess clot resolution or propagation 

• • Monitor for new symptoms (e.g., dyspnea—concern for PE) 

• • Regular follow-up for anticoagulation if initiated 

• • Assess for underlying malignancy if unexplained/recurrent 

• • Lifestyle modification for recurrence prevention 

• • Compression therapy for varicose veins if present