Ascending thrombophlebitis of the great saphenous vein. Treatment tactics for thrombophlebitis and phlebothrombosis of the lower extremities. Treatment regimens for venous pathology associated with blood clots

Thrombosis of the great saphenous vein is the most common complication of varicose or postthrombophlebitic disease. At the first symptoms of thrombosis, the patient should immediately consult a doctor, to receive a referral for emergency surgery.

How to detect thrombosis of the great saphenous vein of the legs

If we talk about the clinical picture, thrombosis occurs against the background of inflammation of surrounding tissues. Along the vein, a dense infiltrate may be palpated, the subcutaneous tissue is infiltrated, and the patient experiences sharp pain when walking. But with the help of palpation, a phlebologist cannot make an accurate diagnosis, so angiographic research methods are used.

If thrombosis of the great saphenous vein is localized above the middle third of the thigh, this can be considered an embolic disease. Additional research is being carried out to exclude the possibility of a thrombus passing beyond the saphenofemoral anastomosis.

Treatment of thrombosis

Saphenous vein thrombosis can only be treated under the direct supervision of an experienced physician. The patient is recommended bed rest, elastic bandaging to fix the blood clot, heparin-containing gels or ointments, phlebotonics, and anticoagulants.
If ascending thrombophlebitis is diagnosed, the patient is indicated. Most often, a crossectomy is performed, when the veins are ligated, preventing upward migration of the clot.

For quotation: Kiyashko V.A. Thrombophlebitis of the superficial veins: diagnosis and treatment // Breast Cancer. 2003. No. 24. S. 1344

D This type of pathology is a very common disease of the venous system, which is encountered by doctors of any specialty.

Currently, terms such as phlebothrombosis and varicothrombophlebitis are also often used in medical practice. All of them are legal to use, but the following points should be taken into account. Phlebothrombosis is considered as an acute obstruction of a vein as a result of hypercoagulation, which is the leading mechanism. But at the same time, after 5-10 days, the resulting thrombus causes reactive inflammation of the tissues surrounding the vein with the development of phlebitis, that is, phlebothrombrosis transforms into thrombophlebitis .

The term “varicothrombophlebitis” clearly indicates, in fact, the initial cause of thrombosis that occurs against the background of varicose veins that the patient already had.

The pathology of the venous system listed above in the overwhelming majority of clinical cases occurs in the large saphenous vein system and much less often in the small saphenous vein system.

Thrombophlebitis of the veins in the upper extremities is extremely rare, and the main provoking factors for their occurrence are multiple punctures for administering medications or prolonged placement of a catheter in a superficial vein.

Particular attention should be paid to patients with spontaneously occurring thrombi on the upper and lower extremities, not associated with iatrogenic effects. In such cases, the phenomenon of thrombophlebitis can be suspected as a manifestation of a paraneoplastic reaction caused by the presence of an oncological pathology in the patient, requiring an in-depth multifaceted examination.

Thrombosis in the superficial venous system is provoked by the same factors that cause thrombosis of the deep venous system of the lower extremities. These include: age over 40 years, the presence of varicose veins, cancer, severe disorders of the cardiovascular system (cardiac decompensation, occlusion of the main arteries), physical inactivity after major operations, hemiparesis, hemiplegia, obesity, dehydration, common infections and sepsis, pregnancy and childbirth, taking oral contraceptives, limb trauma and surgical interventions in the area of venous trunks.

Thrombophlebitis can develop in any part of the superficial venous system , with the most common localization on the lower leg in the upper or middle third, as well as the lower third of the thigh. The overwhelming number of cases of thrombophlebitis (up to 95-97%) were noted in the basin of the great saphenous vein (Kabirov A.V. et al., Kletskin A.E. et al., 2003).

The further development of thrombophlebitis can actually occur in two ways:

1. Relatively favorable course of the disease , against the background of the treatment, the process stabilizes, thrombus formation stops, inflammation subsides and the process of organizing a blood clot begins, followed by recanalization of the corresponding part of the venous system. But this cannot be considered a cure, because... Damage to the initially altered valve apparatus always occurs, which further aggravates the clinical picture of chronic venous insufficiency.

Clinical cases are also possible when a fibrotic thrombus tightly obliterates the vein and its recanalization becomes impossible.

2. The most unfavorable and dangerous option in terms of the development of local complications - ascending thrombosis along the great saphenous vein to the fossa ovale or the transition of the thrombotic process through the communicating veins to the deep venous system of the leg and thigh.

The main danger of the course of the disease according to the second option is the threat of developing a complication such as pulmonary embolism (PE), the source of which can be a floating thrombus from the system of the small or great saphenous vein, as well as secondary thrombosis of the deep veins of the lower extremities.

It is quite difficult to judge the frequency of thrombophlebitis among the population, but if we take as a basis the fact that among patients hospitalized in surgical departments with this pathology, more than 50% had varicose veins, then taking into account the millions of patients with this pathology in the country, this figure looks very impressive and the problem is acquiring great medical and social significance.

The age of patients ranges from 17 to 86 years and even older, and the average age is 40-46 years, that is, the working population.

Considering the fact that with thrombophlebitis of the superficial veins, the patient’s general condition and well-being, as a rule, do not suffer and remain quite satisfactory, this creates for the patient and his relatives the illusion of relative well-being and the possibility of various methods of self-medication.

As a result, such behavior of the patient leads to late referral for qualified medical care, and often the surgeon is faced with complicated forms of this “simple” pathology, when high ascending thrombophlebitis or deep vein thrombosis of the limb occurs.

Clinical picture

The clinical picture of the disease is quite typical in the form local pain in the projection of the saphenous veins at the level of the leg and thigh with the involvement of the tissues surrounding the vein in the process, up to the development of sharp hyperemia of this zone, the presence of compactions not only of the vein, but also of the subcutaneous tissue. The longer the zone of thrombosis, the more pronounced the pain in the limb, which forces the patient to limit its movement. Hyperthermic reactions in the form of chills and an increase in temperature to 38-39°C are possible.

Quite often, even a banal acute respiratory disease becomes a provoking moment for the occurrence of thrombophlebitis, especially in patients with varicose veins of the lower extremities.

The examination is always carried out from both sides - from the foot to the groin area. Attention is drawn to the presence or absence of pathology of the venous system, the nature of changes in skin color, local hyperemia and hyperthermia, and swelling of the limb. Severe hyperemia is typical for the first days of the disease; it gradually decreases by the end of the first week.

When thrombophlebitis is localized in the small saphenous vein, local manifestations are less pronounced than when the trunk of the great saphenous vein is affected, which is due to the peculiarities of the anatomy. The superficial layer of the shin's own fascia, covering the vein, prevents the transition of the inflammatory process to the surrounding tissues. The most important point is to find out the timing of the onset of the first symptoms of the disease, the speed of their increase, and whether the patient has attempted to influence the process with medication.

So, according to A.S. Kotelnikova et al. (2003), the growth of a blood clot in the great saphenous vein system is up to 15 cm per day. It is important to remember that in almost a third of patients with ascending thrombosis of the great saphenous vein, its true upper limit is located 15-20 cm above the level determined by clinical signs (V.S. Savelyev, 2001), that is, this fact should every surgeon should take into account when advising a patient with thrombophlebitis of a vein at the hip level, so that there is no undue delay in the operation aimed at preventing pulmonary embolism.

It should also be considered inappropriate to administer local anesthetics and anti-inflammatory drugs to the area of the thrombosed vein on the thigh, since, while relieving pain, this does not prevent the growth of the thrombus in the proximal direction. Clinically, this situation becomes difficult to control, and duplex scanning can only really be used in very large medical institutions.

Differential diagnosis should be carried out with erysipelas, lymphangitis, dermatitis of various etiologies, erythema nodosum.

Instrumental and laboratory diagnostics

For a very long time, the diagnosis of thrombophlebitis of the superficial veins was made by a doctor based only on the clinical symptoms of the disease, since there were virtually no non-invasive methods for characterizing venous blood flow. The introduction of ultrasound diagnostic methods into practice has opened a new stage in the study of this common pathology. But the clinician must know that among ultrasound methods for diagnosing venous thrombosis, the decisive role is given to duplex scanning, since only with its help can one determine a clear boundary of thrombosis, the degree of organization of the thrombus, the patency of the deep veins, the condition of the communicants and the valve apparatus of the venous system. Unfortunately, the high cost of this equipment still sharply limits its practical use in outpatient and inpatient settings.

This study is indicated primarily for patients with suspected embologenic thrombosis, that is, when there is a transition of a thrombus from the superficial to the deep venous system through the sapheno-femoral or sapheno-popliteal anastomosis.

The study can be carried out in several projections, which significantly increases its diagnostic value.

Phlebographic examination

The indications for it have been sharply narrowed. The need to perform it arises only in the event of a thrombus spreading from the great saphenous vein to the common femoral and iliac vein. Moreover, this study is carried out only in cases where the results of duplex scanning are doubtful and their interpretation is difficult.

Laboratory diagnostic methods

In a routine clinical blood test, attention is paid to the level of leukocytosis and the level of ESR.

It is advisable to study C-reactive protein, coagulogram, thrombelastogram, prothrombin index level and other indicators characterizing the state of the coagulation system. But the scope of these studies is sometimes limited by the capabilities of the laboratory service of a medical institution.

Treatment

One of the important points that determine the outcome of the disease and even the fate of the patient is the choice of tactics for the optimal treatment option for the patient.

If thrombophlebitis is localized at the level of the lower leg, the patient can undergo treatment on an outpatient basis, under the constant supervision of a surgeon. In these conditions, it is necessary to explain to the patient and his relatives that if signs of thrombosis spreading to the hip level appear, the patient may need to be hospitalized in a surgical hospital. Delay in hospitalization is fraught with the development of complications, including the occurrence of pulmonary embolism.

In cases where thrombophlebitis at the level of the leg, treated for 10-14 days, does not respond to regression, the question of hospitalization and more intensive treatment of the disease should also be raised.

One of the main issues in the treatment of patients with thrombophlebitis of the superficial veins is the discussion the need for the patient to comply with strict bed rest .

It is now a recognized fact that strict bed rest is indicated only for patients who already had clinical signs of pulmonary embolism or there are clear clinical data and the results of instrumental studies indicate the embologenic nature of thrombosis.

The patient's physical activity should be limited only to severe physical activity (running, lifting heavy objects, performing any work that requires significant muscle tension in the limbs and abdominals).

General principles of treatment of superficial vein thrombophlebitis

These principles are truly general for both conservative and surgical treatment of this pathology. The main objectives of treatment these patients are:

Act as quickly as possible on the source of thrombosis and inflammation to prevent its further spread.
Try to prevent the transition of the thrombotic process to the deep venous system, which significantly increases the risk of developing pulmonary embolism.
Treatment should be a reliable method of preventing recurrent thrombosis of the venous system.
The treatment method should not be strictly fixed, since it is determined primarily by the nature of the changes occurring in the limb in one direction or another. That is, it is quite logical to switch or complement one treatment method with another.

Undoubtedly, conservative treatment indicated for the absolute majority of patients with “low” superficial thrombophlebitis of the saphenous veins.

Once again, it should be emphasized that reasonable physical activity of the patient improves the function of the muscle pump, which is the main determinant in ensuring venous outflow in the inferior vena cava system.

The use of external compression (elastic bandage, stockings, tights) in the acute phase of inflammation can cause some discomfort, so this issue should be resolved strictly individually.

The issue of using antibiotics in this category of patients is quite controversial. The doctor must remember the possible complications of this therapy (allergic reactions, intolerance, provocation of blood hypercoagulation). Also, the question of the advisability of using anticoagulants (especially direct action) in this group of patients is far from clear.

The doctor must remember that the use of heparin after 3-5 days can cause thrombocytopenia in the patient, and a decrease in the platelet count by more than 30% requires discontinuation of heparin therapy. That is, difficulties arise in controlling hemostasis, especially in an outpatient setting. Therefore, it is more appropriate to use low molecular weight heparins (dalteparin, nadroparin, enoxaparin), since they extremely rarely cause the development of thrombocytopenia and do not require such careful monitoring of the coagulation system. The positive thing is that these drugs can be administered to the patient once a day. A course of treatment requires 10 injections, and then the patient is transferred to indirect anticoagulants.

In recent years, ointment forms of heparin (Lioton-gel, Gepatrombin) have appeared for the treatment of these patients. Their main advantage is fairly high doses of heparin, which are delivered directly to the site of thrombosis and inflammation.

Of particular note is the targeted effect on the area of thrombophlebitic changes of the drug Hepatrombin (“Hemofarm” - Yugoslavia), produced in the form of ointment and gel.

Unlike Lyoton, it contains 2 times less heparin, but additional components - allantoin and dexpanthenol, which are part of the ointment and gel "Gepatrombin", as well as pine essential oils, which are part of the gel, have a pronounced anti-inflammatory effect, reduce skin itching and local pain in the area of thrombophlebitis. That is, they help relieve the main symptoms of thrombophlebitis. The drug Gepatrombin has a strong antithrombotic effect.

It is used topically by applying a layer of ointment to the affected areas 1-3 times a day. If there is an ulcerative surface, the ointment is applied in the form of a ring up to 4 cm wide around the perimeter of the ulcer. The good tolerability of the drug and the versatility of its effect on the pathological focus puts this medicine at the forefront in the treatment of patients with thrombophlebitis both on an outpatient basis and during treatment in hospitals. Hepatrombin can be used in a complex of conservative treatment or as a means aimed at relieving inflammation of the venous nodes after the Troyanov-Trendelenburg operation, as a method of preparation for the second stage of the operation.

The complex of conservative treatment of patients should include non-steroidal anti-inflammatory drugs , which also have an analgesic effect. But the clinician must remember to exercise extreme caution when prescribing these drugs to patients with diseases of the gastrointestinal tract (gastritis, peptic ulcer) and kidneys.

Already well known to doctors and patients, they have proven themselves in the treatment of this pathology. phlebotonics (rutoside, troxerutin, diosmin, gingko biloba and others) and disaggregants (acetylsalicylic acid, pentoxifylline). In severe cases with extensive phlebitis, intravenous transfusions of rheopolyglucin 400-800 ml IV for 3 to 7 days are indicated, taking into account the cardiac status of the patient due to the danger of hypervolemia and the threat of developing pulmonary edema.

Systemic enzyme therapy has limited use in practice due to the high cost of the drug and a very long course of treatment (from 3 to 6 months).

Surgery

The main indication for surgical treatment of thrombophlebitis, as previously indicated, is the growth of a blood clot along the great saphenous vein above the middle third of the thigh or the presence of a blood clot in the lumen of the common femoral or external iliac vein, which is confirmed by phlebography or duplex scanning. Fortunately, the latter complication does not occur so often, in only 5% of patients with ascending thrombophlebitis (I.I. Zatevakhin et al., 2003). Although individual reports indicate a significant frequency of this complication, reaching even 17% in this group of patients (N.G. Khorev et al., 2003).

Methods of anesthesia - different options are possible: local, conduction, epidural anesthesia, intravenous, intubation anesthesia.

The position of the patient on the operating table is of certain importance - the foot end of the table should be lowered.

A generally accepted operation for ascending thrombophlebitis of the great saphenous vein is Troyanov-Trendelenburg operation .

The surgical approach used by most surgeons is quite typical - an oblique incision below the inguinal fold according to Chervyakov or the inguinal fold itself. But at the same time, it is important to take into account the main clinical point: if there are instrumental data or clinical signs of a thrombus moving into the lumen of the common femoral vein, then it is more advisable to use a vertical incision that provides control over the thrombosed great saphenous vein and the trunk of the common femoral vein, when it is sometimes necessary to clamp it moment of thrombectomy.

Some technical features of the operation:

1. Mandatory isolation, intersection and ligation of the trunk of the great saphenous vein in the area of its mouth.

2. When opening the lumen of the great saphenous vein and detecting a blood clot in it that extends beyond the level of the ostial valve, the patient must hold his breath at the height of inspiration during surgery under local anesthesia (or this is done by an anesthesiologist for other types of anesthesia).

3. If the thrombus “does not form on its own,” then a balloon catheter is carefully inserted through the saphenofemoral anastomosis at the height of inspiration and thrombectomy is performed. Retrograde blood flow from the iliac vein and antegrade blood flow from the superficial femoral vein are checked.

4. The stump of the great saphenous vein must be sutured and ligated; it must be short, since a stump that is too long is an “incubator” for the occurrence of thrombosis, which creates a threat of the development of pulmonary embolism.

In order to discuss options for this routine operation, it should be noted that during the Troyanov-Trendelenburg operation, some surgeons suggest performing thrombectomy from the great saphenous vein and then injecting a sclerosant into it. The expediency of such manipulation is questionable.

The second stage of the operation - removal of thrombosed varicose nodes and trunks is carried out according to individual indications in a period of 5-6 days to 2-3 months as local inflammation is relieved, in order to avoid suppuration of wounds in the postoperative period, especially with trophic skin disorders.

When performing the second stage of the operation, the surgeon must ligate the perforating veins after preliminary thrombectomy, which improves the healing process.

All conglomerates of varicose nodes must be removed to avoid the further development of severe trophic disorders.

A very wide range of general surgeons and angiosurgeons are involved in the surgical treatment of this group of patients. The apparent simplicity of treatment sometimes leads to tactical and technical errors. Therefore, this topic is almost constantly present at scientific conferences.

Literature:

5. Revskoy A.K. “Acute thrombophlebitis of the lower extremities” M. Medicine 1976

6. Savelyev V.S. "Phlebology" 2001

7. Khorev N.G. “Angiology and Vascular Surgery” No. 3 (supplement) 2003, pp. 332-334.

Thrombophlebitis of the saphenous veins of the lower extremities or superficial thrombophlebitis is a disease in which blood clots appear in the lumen of the saphenous veins. Since the veins are located close to the skin, this phenomenon is accompanied by inflammation - redness of the skin, pain, local swelling.

In fact, saphenous vein thrombophlebitis is a “double” disease. Because, firstly, the venous walls themselves become inflamed. And secondly, a blood clot forms in the vein - a thrombus.

Superficial thrombophlebitis in the vast majority of cases manifests itself as an acute disease.

More often, varicose-transformed tributaries of the great (and/or small) saphenous vein, as well as perforating veins, are thrombosed. But if left untreated, thrombosis spreads to the largest (small) saphenous vein itself and further to the deep veins.

Causes of thrombophlebitis of superficial veins

The cause of any thrombosis is a combination of three factors:

change in the configuration of the vein (for example, varicose transformation) and, as a result, “swirling” of blood in the lumen of the vessel;
“thickening” of the blood – a tendency (hereditary or acquired) to thrombosis;
damage to the vein wall (injection, trauma, etc.).

The main and most common cause of superficial thrombophlebitis is considered to be varicose veins. Also, the most common risk factors are:

genetic predisposition;
pregnancy and childbirth;
obesity, physical inactivity;
endocrine and oncological diseases.

Superficial thrombophlebitis: symptoms and manifestations

In the initial stages, superficial thrombophlebitis of the lower extremities may not be very noticeable in its manifestations. Mild redness of the skin, burning, minor swelling - many patients simply do not pay attention to all this. But the clinical picture changes very quickly, and the signs of thrombophlebitis of the superficial veins become noticeable and very uncomfortable:

the appearance of “nodules” and compactions in the vein;
edema;
acute pain;
local increase in temperature;
change in skin color in the area of the inflamed vein.

Treatment of superficial thrombophlebitis

To treat thrombophlebitis of the superficial veins, different techniques and their combinations are used.

More often this may be conservative treatment:

compression therapy – wearing compression stockings, special elastic bandaging;
taking non-steroidal anti-inflammatory and painkillers;
locally, in the area of inflammation - cold;
according to indications - taking medications that “thin” the blood.

Emergency surgical treatment of acute thrombophlebitis of the saphenous veins is prescribed, as a rule, in cases where thrombosis does not affect the tributaries, but directly the large or small saphenous veins. Thus, with ascending thrombophlebitis of the great or small saphenous vein, the trunk of the main saphenous vein is thrombosed directly. When thrombosis of the great saphenous vein spreads to the thigh, thrombophlebitis is considered ascending. For the small saphenous vein, this is the middle and upper third of the leg.

In this case (if technically possible), either endovenous laser obliteration or crossectomy is used - ligation of the great (small) saphenous vein along with its tributaries.

If ascending thrombophlebitis has already led to the penetration of a blood clot into the deep veins, this is fraught with the occurrence of a pulmonary embolism - detachment of a blood clot and blockage of the pulmonary artery. This situation occurs when thrombosis spreads from the saphenous veins to the deep (“muscular”) veins.

In this situation (if technically possible), the blood clot is removed from the deep veins and crossectomy is performed - ligation of the saphenous vein at the mouth.

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GSV thrombosis

Thrombosis of the great saphenous vein or in abbreviation BVP thrombosis– occurs very often with varicose veins of the saphenous veins of the lower extremities. A blood clot forms in the great saphenous vein, blocking the flow of blood. Blood begins to collect in a certain area and fill the vein.

Causes of thrombosis of the great saphenous vein

Reason bvp thrombosis most often it is the expansion of veins and their deformation. The blood begins to circulate more slowly and forms clots that clog the vein. There are several factors contributing to the formation of this disease:

Age. The disease often occurs in people over 60 years of age;

Obesity. Excess weight is a heavy physical load for the body. A person is inactive, the blood begins to circulate more slowly and becomes thicker. As a result, blood clots form in the vessels and veins;

Long bed rest;

Serious injuries due to which a person cannot move normally for a long time;

Operations performed in the lower extremities and pelvis;

Pregnancy, childbirth and the postpartum period;

The body's tendency to thrombosis. This is a congenital disease;

Long-term use of hormonal drugs.

A varicose thrombus can form anywhere in the saphenous vein, very often in the thighs and lower legs. The great saphenous vein is affected by blood clots along with its tributaries. The outcome of thrombosis may vary. In rare cases, it resolves on its own or after therapy. It also happens that a blood clot begins to grow into connective tissues and dissolves, destroying the valve apparatus of the vein. In some cases, a blood clot completely blocks a vein, resulting in sclerosis, or the blood clot gradually grows in size and becomes larger. This outcome of the disease is the most unfavorable because such thrombosis turns into thrombophlebitis and can spread to the deep venous system, causing pulmonary thromboembolism, a serious disease that very often ends in death.

Signs of the disease

It often happens that thrombosis of the great saphenous vein occurs unexpectedly. But there are also classic signs of the disease:

Sharp pain when palpating the sore spot;

Redness in the area of the changed vein;

Feeling of heaviness in the affected area;

Trauma in the vein area;

Viral diseases such as influenza.

Symptoms depend on the location of the blood clot, the complexity and neglect of the process. Basically, the patient does not feel unwell. He has slight pain and heaviness in his legs, especially when walking, and sometimes feels slightly unwell, which is expressed by weakness, chills and a slightly elevated temperature. But overall, there are no serious complaints. The most important thing is to determine the exact location of the blood clot. It should also be taken into account that if thrombosis begins to spread to the popliteal vein, often this process does not have any symptoms, since the thrombosis is floating. Therefore, when diagnosing, it is better to use the instrumental method.

Treatment depends on the location of the clot. But in any case, the disease is serious, and the patient must be under the supervision of doctors and be hospitalized. But strict bed rest is not provided. Only for those who have relapses of the disease. You can move, but you cannot run, lift weights, play sports and various types of physical activity.

The most important thing in the treatment process is to prevent the spread of thrombosis as quickly as possible. Treatment must be very effective so that recurrence or thrombosis does not subsequently occur in other areas. Before prescribing treatment, it is necessary to take into account the place, part of the body where thrombosis of the great saphenous vein has formed. Several treatment methods can be combined if necessary.

If thrombophlebitis occurs in a mild form, you can get by with medical treatment and compresses. The affected limb must be covered with an elastic bandage or golf bandage. If the disease is in an acute phase, bandages may cause discomfort. If a blood clot in a vein grows in size, surgery is urgently needed. After surgery, you must follow your doctor's instructions. Our clinic will help you get better and completely get rid of the disease. We will do everything to make you healthy and happy again!

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Endovasal laser coagulation of veins. 1st category of complexity. including anesthesia support (local anesthesia).

Lymphopressotherapy course 10 procedures. Accepted by Phlebologist, Candidate of Medical Sciences

The appointment is conducted by a surgeon of the highest category, Doctor of Medical Sciences, Professor Komrakov. V.E.

A single session of sclerotherapy throughout the entire lower limb (foam sclerotherapy, microsclerotherapy).

Varicose veins, blood clots, valve insufficiency, swelling in the legs

- all this is a reason to perform an ultrasound scan of the veins of the lower extremities

and consult a phlebologist.

Lymphopressotherapy is indicated for

swelling of the lower extremities, lymphostasis.

It is also carried out for cosmetological purposes.

Thrombosis of the great saphenous vein

Varicose veins are a fairly serious disease that cannot be ignored. Varicose veins form in the lower extremities and affect the deep saphenous veins. Gradually, blood fills the veins, which is why they become less elastic and lengthen, knots form, the valves in the vessels begin to work poorly and cannot normally push blood up to the heart.

This disease occurs for the following reasons:

High venous pressure due to a sedentary lifestyle;

Female gender, since most often this disease occurs in women. Women often wear high heels, wear uncomfortable shoes, carry children and give birth. All this contributes to the appearance of vein diseases;

Heredity. If someone in the family already has varicose veins, the disease can be inherited to a younger generation;

Heavy physical activity. Gradually, blood begins to linger in the lower extremities, and normal blood circulation is disrupted. Instead of moving up towards the heart, the blood remains in the legs and gradually accumulates in the veins.

Symptoms of varicose veins

Symptoms include:

Heaviness in the legs;

Bursting pain in the calf area;

Leg cramps;

Veins overflowing with blood become visible through the skin, they are curved and blue in color.

If you ignore and do not treat varicose veins, serious complications often begin - the formation of thrombosis in the area of the great saphenous vein. Thrombosis is the formation of blood clots in veins and blood vessels. Blood clots attach to the walls of blood vessels and interfere with the flow of blood. Gradually, there are more and more blood clots, and they can completely block the lumen of the vessel. Blood clots come in various shapes, some are long, similar to leeches; they hold only one part to the wall of the vessel, the rest is in free movement. At any moment, such a blood clot can break off and travel with blood into large veins or arteries. This is dangerous because blood clots often clog the arteries of the lungs, causing the patient to experience respiratory failure and pulmonary embolism. It happens that such a disease ends in the death of a person. Symptoms thrombosis of the great saphenous vein the following:

Pain in the legs, especially in the area of the vein affected by blood clots. There is pain even when the legs are at rest, and when palpating;

Vein overflowing with blood;

You can feel blood clots in a vein;

Often the disease process begins in the upper region of the leg and gradually, and sometimes very quickly, in just a few hours, begins to spread to the area of the great saphenous vein. It happens that the causes of thrombosis are blood clots that break away from the walls of blood vessels and penetrate with blood into the great saphenous vein. A sick person needs the help of a specialist, so you can’t hesitate; you should definitely contact a phlebologist - a doctor who diagnoses diseases of the veins and blood vessels. He will examine the affected limb and, after diagnosis, will be able to prescribe effective treatment. Often thrombosis of the great saphenous vein They urgently operate to remove diseased veins and blood clots. Gradually, blood circulation improves and blood can move normally through the veins.

After the operation, the patient must wear an elastic bandage, especially if he needs to walk somewhere. You always need to monitor the veins of your legs, take care of your health, do special exercises for prevention, it is advisable to raise your legs up after each busy day and lie in this position for a while, this helps blood circulate better. It is useful to go swimming and run short distances. If a person is forced to constantly be in one position at work, standing or sitting, after work you can walk instead of traveling by transport. If there are any indicators indicating problems with the veins, you need to be examined by a doctor. After all, the earlier a disease is detected, the easier it is to cure it without surgery with the help of medications. Come to our clinic! Our doctors will help you cope with thrombosis and, if necessary, perform surgery, after which your legs will be healthy again.

The meaning of the term Acute Thrombophlebitis of the Saphenous Veins of the Lower Extremities in the Encyclopedia of the Scientific Library

Acute Thrombophlebitis of the Saphenous Veins of the Lower Extremities- Most often occurs as a result of mechanical and chemical damage to the venous wall, after intravenous administration of drugs, often as a reactive process during influenza infection, sore throat, pneumonia, tuberculosis, typhoid, etc. It is very often observed in people suffering from varicose veins of the saphenous veins of the lower extremities, in particular in 31.5% of pregnant women with varicose veins of the saphenous veins.

The inflammatory process is mainly localized in the wall of the great saphenous vein of the leg, thigh and in their tributaries, mainly affects the saphenous veins of the upper third of the leg, lower and middle thirds of the thigh and can be focal, segmental or widespread.

Clinic and diagnosis. Acute thrombophlebitis of the saphenous veins of the lower extremities manifested by moderate or severe pain and thickening (infiltrate) along the saphenous vein, hyperemia of the skin above it. When surrounding tissues are involved in the inflammatory process, periphlebitis occurs; general health does not suffer with limited, segmental thrombophlebitis of the saphenous veins. With a widespread thrombophlebic process, the general condition of patients worsens, body temperature rises (up to 38° or more). There is a slight leukocytosis with a moderate shift of the formula to the left and an increased ESR. An important pathognomonic sign acute thrombophlebitis of the saphenous veins is the absence of swelling of the affected limb. After a few days, the acute process becomes subacute, and after 2 - 3 weeks the inflammatory phenomena stop, but only after 2 - 4 months the lumen of the affected vein is restored. Acute thrombophlebitis of the saphenous veins can cause severe complications that arise as a result of the spread of the thrombotic process from the saphenous to the main veins: a) through the mouth of the great saphenous vein of the thigh; b) through the mouth of the small saphenous vein of the leg; c) through the communicating veins.

The thrombotic process from the saphenous veins to the main vein most often spreads when there is insufficient fixation of the thrombus to the vein wall. In this case, a “floating thrombus” is formed, which can reach a length of 15–20 cm and penetrate into the femoral vein. When thrombosis spreads proximally, pain is noted along the anteromedial surface of the thigh. Therefore, if there are clinical signs of acute thrombophlebitis of the great saphenous vein of the thigh at the border of the middle and upper thirds, the question of emergency surgery should be raised - phlebectomy of the great saphenous vein at its mouth - as a preventive measure for the spread of thrombosis to the femoral vein. It must be remembered that “floating blood clots” are a potential source of pulmonary embolism.

In the postoperative period, antibiotics and anticoagulants are indicated. Of the latter, the most commonly used is finilin 0.03 g 1 - 2 times a day under the control of the prothrombin index and blood clotting time. In this case, blood prothrombin should remain at the same level - 0.60 - 0.70. It is necessary to discontinue finilin by gradually reducing the daily dose to 1/4 tablet/day within 10 days from the moment the normal blood prothrombin level stabilizes. After discontinuation of finilin, patients should receive acetylsalicylic acid (ASA) 0.25 g 4 times a day, which inhibits platelet aggregation and adhesion, in addition, does not require special monitoring of the state of the blood coagulation system.

Thrombophlebitis of the saphenous veins

Thrombophlebitis of the saphenous veins(thrombophlebitis of the superficial veins or superficial thrombophlebitis) is an inflammatory disease of the superficial veins. Most often, thrombophlebitis damages the superficial veins of the lower extremities and groin area. Thrombophlebitis develops in people suffering from varicose veins.

Unlike deep veins, with thrombophlebitis of the saphenous veins, a pronounced inflammatory reaction develops, which is accompanied by severe pain. In turn, inflammation damages the vein wall, which contributes to the development and progression of thrombosis. In addition, the superficial veins are not surrounded by muscles, therefore, with muscle contraction, the risk of destruction of the blood clot and migration of its pieces with the bloodstream (embolism) does not increase, so superficial thrombophlebitis is potentially not dangerous.

Sometimes thrombophlebitis can occur again, this especially often occurs with cancer or other serious diseases of the internal organs. When thrombophlebitis occurs as a concomitant disease with an oncological process in the body, this condition is also called Trousseau syndrome.

Symptoms of superficial thrombophlebitis

The first symptoms of thrombophlebitis are local pain and swelling; the skin in the area of the vein in which thrombophlebitis has developed becomes brown or red and hard. Since a blood clot has formed in the vein, it becomes denser along its length.

Diagnosis of superficial thrombophlebitis

The diagnosis is usually made after collecting anamnestic data and examination. To confirm the diagnosis, color duplex ultrasound scanning is performed.

In most cases, thrombophlebitis of the superficial veins goes away on its own. Treatment usually includes pain relievers such as aspirin or other non-steroidal anti-inflammatory drugs, which help reduce pain and inflammation. Antiplatelet agents and anticoagulants (blood thinning medications) are also used to reduce blood clotting. In case of severe thrombophlebitis, local anesthesia is applied, the blood clot is removed and then a compression bandage is put on, which must be worn.

If thrombophlebitis develops in the superficial veins in the pelvic area, then there is a high probability of migration of blood clots and the development of deep vein thrombophlebitis and pulmonary embolism. To prevent the development of these complications in thrombophlebitis of the deep and superficial veins in the pelvic area, emergency surgical treatment in a hospital setting is recommended.

Thrombosis and thrombophlebitis of the saphenous veins

It is known that ascending thrombophlebitis in the system of the great or small saphenous vein accounts for up to 3% of all causes of deep vein thrombosis. At the same time, in emergency angiosurgical practice, the issues of diagnosis and treatment of this pathology remain controversial and not fully resolved; a good phlebologist must navigate this issue.

Every year, up to 80 patients diagnosed with thrombophlebitis of the saphenous veins of the lower extremities are delivered to the emergency department of City Hospital No. 1 by ambulance from clinics and various medical institutions in the city of Irkutsk. After examination by an angiosurgeon and ultrasound examination, from 35 to 45 patients are hospitalized in the vascular surgery department. The most common diagnostic error is erysipelas of the lower extremities.

The predominant cause leading to thrombosis and thrombophlebitis of the saphenous veins was varicose veins with severe disturbances of venous hemodynamics and gross morphological changes in the walls of the veins. In isolated cases, the trigger for the development of venous thrombosis was cancer, injuries to the lower extremities, long-term surgical interventions using muscle relaxants, various skin dermatitis or thrombophilic conditions. In most cases, the system of the great saphenous vein was involved in the inflammatory process, and cases of thrombosis of the small saphenous vein were isolated. The age of the patients ranged from 34 to 75 years, of which 55% of all patients were still over 55 years of age. Among the total number of admissions, women of childbearing age made up 12%.

From 2000 to 2004 In the Department of Vascular Surgery, 166 patients were operated on as an emergency. Most operations were performed under local anesthesia. In 25 patients, thrombectomy was performed from the mouth of the great saphenous vein and a loose thrombus extending to the femoral vein was removed. It was repeatedly confirmed intraoperatively that the level of thrombosis of the trunk of the saphenous veins was always significantly higher (by 10-15 cm) determined preoperatively visually and by palpation.

Clinically reliably established cases of small focal pulmonary embolism after such operations were isolated. There were no cases of massive pulmonary embolism after these operations. Most patients in the postoperative period received complex drug treatment, including heparinization, and were prescribed an active motor regimen.

What are the symptoms and how to treat thrombophlebitis of the superficial veins of the lower extremities

Thrombophlebitis of the superficial veins of the lower extremities is a disease characterized by the development of an inflammatory process in the superficial venous trunks of the legs and the formation of blood clots in this place. Inflammation and thrombus formation are closely related and form a vicious circle of disease. Professions associated with prolonged standing, prolonged bed rest, diseases of the hematopoietic organs and blood, varicose dilatation of the superficial veins of the legs, pregnancy are risk factors for the development of thrombophlebitic lesions of the venous vessels of the lower extremities.

Thrombophlebitis of the superficial vessels of the legs significantly reduces the patient’s quality of life and causes a lot of problems and inconveniences. In addition to a pronounced cosmetic defect, there is pain in the legs, a feeling of heaviness and a symptom of distension. All this requires immediate initiation of treatment for the disease. At the initial stages of development of lesions of the superficial veins of the legs, drug treatment is predominantly prescribed. A long-term disease rarely resolves without surgical intervention.

Clinically, thrombophlebitic damage to the superficial vessels of the lower extremities is a disease of the great saphenous vein. The small saphenous vein is included in the process much less frequently. Usually the disease develops against the background of varicose dilated venous trunks.

You can understand whether thrombophlebitis has begun or whether it is varicose dilatation by the following signs: with varicose veins, the skin is not red, the temperature of the body and skin over the nodes is normal, there is no pain. In a lying position, the blood filling the varicose nodules will go into deeper veins and the nodules themselves will become smaller.

Acute superficial thrombophlebitis is characterized by pain in the lower extremities, swelling, redness and the appearance of dense and painful venous trunks under the skin. During the chronic course, periods of remission and health alternate with periods of an acute process, which is characterized by all of the above symptoms. Due to long-term superficial thrombophlebitis, trophic skin ulcers often develop, and the color of the skin over the affected veins changes. During the period of remission, external signs of the disease may not be detected.

Thrombophlebitis of the superficial veins is rarely accompanied by any complications. The inflammatory reaction is more pronounced in superficial vessels than in deep ones, which ensures the adhesion of the thrombotic mass to the venous wall. This process is why the likelihood of a blood clot breaking off in a superficial vein is lower, although it still exists. Inflammation from superficial vessels is often accompanied by the spread of the process to nearby subcutaneous fat or arteries.

Conservative therapy of thrombophlebitis

Considering all the clinical manifestations of thrombophlebitis of the superficial veins of the legs, the risk of possible complications and the development of concomitant pathologies, it becomes clear that treatment must begin with the earliest signs of the disease. Treatment is usually prescribed by a phlebologist or therapist. Therapeutic measures are aimed at reducing blood viscosity, stopping the ascending spread of thrombophlebitic lesions, as well as the transition of inflammation and thrombosis from superficial venous vessels to deep veins or arteries, relieving the inflammatory reaction, preventing repeated episodes of the disease and its complications.

Treatment of thrombophlebitis can be general and local. If superficial venous vessels are affected, therapeutic measures can be carried out at home. The exception is a condition threatening pulmonary embolism.

The acute course of superficial thrombophlebitis requires strict bed rest to reduce the risk of blockage of the pulmonary artery. The optimal posture to improve the outflow of venous blood is with an elevated position of the lower extremities. Plenty of fluid intake is indicated, up to three liters per day, but only if there are no contraindications (kidney disease, heart disease). In case of chronic thrombophlebitis, heat compresses can be used. They improve peripheral blood circulation. In case of acute damage to the veins, heat compresses are contraindicated. To reduce pain during an acute process, a blockade with novocaine according to Vishnevsky and cold compresses are used (only if there is pulsation of the arteries of the foot).

Therapeutic treatment has been successfully used for superficial thrombophlebitis with occlusive thrombi. Therapy consists of the following activities:

Elastic compression.
Drug treatment.
Physiotherapy.
Hirudotherapy.

Elastic compression for thrombophlebitis involves the use of special compression garments and bandaging with elastic bandages. This technique reduces the symptoms of edema and pain by eliminating their cause - weak venous function.

Drug therapy can be general and local. The following medications are used:

strengthening the venous wall;
antiplatelet agents and anticoagulants;
improving microcirculation;
dissolving thrombotic masses;
non-steroidal anti-inflammatory drugs;
antibiotics.

Antibacterial therapy is used for septic thrombophlebitis (caused by any viral or bacterial pathogen). Damage to the superficial veins is usually infectious. Also, such complications as trophic leg ulcers require antibacterial treatment. Antibiotics are not prescribed for prophylactic purposes, as some of them can provoke increased blood clotting and the formation of blood clots.

Anticoagulant therapy helps reduce blood viscosity, thins it, reduces the deposition of thrombotic masses and prevents thrombosis. It is mandatory to prescribe anticoagulants for ascending lesions of the superficial veins of the lower extremities and postthrombophlebitic syndrome. The most common anticoagulants are low molecular weight heparins. The reasons for this: dosages are easy to select, there is no need for coagulation tests, and it is approved for use in pregnant women. With mild damage to the superficial veins of the lower extremities, local anticoagulation therapy is sufficient. To dissolve thrombotic masses and relieve symptoms of vascular blockage in such cases, heparin ointment is used. In addition to reducing blood clotting, the ointment reduces inflammation and reduces the amount of swelling.

Nonsteroidal anti-inflammatory drugs relieve swelling and pain. Non-steroidal drugs relieve inflammation in a short time. If the process is acute, then they are prescribed in the form of intramuscular injections, and then the patient is transferred to tablet forms. The most commonly used drugs from this group are diclofenac, ibuprofen, meloxicam (it can be used for ulcerative lesions of the intestines, stomach and asthmatic disease). To enhance the effect of general non-steroidal anti-inflammatory therapy, topical preparations (ointments, gels) are used.

Angioprotectors, together with non-steroidal anti-inflammatory drugs, quickly eliminate the symptoms of an acute inflammatory process by reducing the permeability of the vascular walls. The most common angioprotector is troxerutin. The duration of therapy with troxerutin is 20 days. It protects the vascular wall. Angioprotectors are available in various dosage forms: tablets, ointments, gels.

They improve the flow properties of blood and effectively thin it with antiplatelet agents. Most often, acetylsalicylic acid preparations (aspirin) are used for these purposes. Aspirin, as a non-steroidal anti-inflammatory drug, not only reduces blood viscosity, but also relieves symptoms of inflammation. Anticoagulants and aspirin should not be used at the same time, as this may cause bleeding.

Polyenzyme preparations dissolve thrombotic masses. These include Wobenzym and Phlogenzym.

Thrombolytics for superficial thrombophlebitis are used in the case of an ascending process or if there is a risk of developing pulmonary embolism. These drugs include the following: streptokinase, urokinase and alteplase. Thrombolytic agents dilute the formed thrombus and restore blood flow through the vessels. Thrombolytics can cause bleeding, so they are used only for life-threatening conditions.

Advanced thrombophlebitis of the superficial veins of the legs is often complicated by trophic ulcerations of the skin. To treat trophic ulcers, systemic antibacterial drugs are prescribed. Damaged tissue is removed, the surface of the ulcer is treated with antiseptics. Ointments are applied to the dried surface of the ulceration to accelerate healing. The most common and effective remedy is Vishnevsky ointment.

Physiotherapy is used as an additional treatment method. Physiotherapeutic effects are aimed directly at the inflamed area with a formed blood clot, as well as areas of the skin affected by trophic ulcers.

UHF therapy. Relieves swelling, inflammatory symptoms, improves lymphatic drainage.
Electrophoresis with drugs. Under the influence of an electric current, medications are delivered to the affected veins.
Magnetotherapy. It has a beneficial effect on the rheological properties of blood, thins it, and has an analgesic and anti-inflammatory effect.

Drug therapy should be based on the individual characteristics of patients. Only a doctor should select the dosage of medications and the necessary combinations. Attempts at self-therapy can result in the development of severe complications: from bleeding from arteries and veins to blockage of the pulmonary trunk.

Acute thrombophlebitis of the superficial vessels of the legs can be treated with hirudotherapy. Treatment with medicinal leeches is especially important if there are contraindications for the use of anticoagulants. Leeches produce a substance that reduces blood viscosity and clotting, and reduces spasm of arteries and veins. Usually, 5 to 10 leeches are placed along the affected vein. Hirudotherapy is used once a week under the supervision of a doctor.

Surgical interventions for thrombophlebitis

Surgical treatment is resorted to if there is no effect from conservative therapy, when there is a high probability of developing pulmonary embolism and when there are symptoms of thrombus melting with purulent exudate.

The following types of surgical intervention are used:

thrombectomy;
ligation of a venous vessel or suturing of a vessel;
the imposition of intervascular anastomosis (connection of arteries and veins);
installing a filter in large venous vessels (inferior vena cava).

An operation aimed at removing thrombotic masses from a vessel is called thrombectomy. This method of restoring blood flow is considered one of the most gentle and does not pose any significant difficulty in implementation.

A modern method of removing blockages from blood vessels is thrombolysis (used for damage to both veins and arteries), carried out using a special catheter. A tube is inserted into the vascular trunk, through which the thrombolytic drug is delivered directly to the location of the thrombus. In this way, large deposits of thrombotic masses can be removed, eliminating the symptoms of complete blockage of veins or arteries.

Prevention of thrombophlebitis

Patients in the postoperative period or forced to remain on bed rest for a long time definitely need preventive measures against blockages of the superficial veins:

long-term use of anticoagulants;
compression products (elastic bandaging, medical underwear);
early rise of patients after surgery, physical therapy.

Thrombosis of the left SVC Good afternoon! Please help me accept.

Good afternoon!. Please help me make the right decision. Ultrasound of the lower extremities on the left: GSV, GSV, GSV, popliteal vein, WSV, patent, the lumens are free, collapse with compression. At the level of the lower leg there is a non-expanded inflow of the GSV. The SVC is dilated. Insufficiency in the SPS and at the level of the trunk. in the middle/3rd leg along the posterior surface, a varicose transformed inflow flows into the trunk, is visualized distally at the level of the entire lower leg. In the middle/3rd leg in the lumen of a filamentous shape, hyperechoic parietal masses, the blood flow is visualized, the lumen collapses during compression. Perforators with valve insufficiency in the v/3, n/3 of the leg. Thrombosis of the left SVC in the stage of incomplete recanalization. Some doctors say to operate, others to treat. What should we do? The man is 42 years old.

Apparently these are traces of thrombosis (that is, when you suffered thrombophlebitis). Treatment options, including laser, are determined in such cases only during a face-to-face consultation.

Thrombosis of the small saphenous vein

Discarding unnecessary speculation about the pathogenesis of these diseases, we note that

in both cases, a blood clot forms in the lumen of the venous vessel and inflammation of the vessel wall and perivasal tissues occurs. The condition of the blood clot is of fundamental importance, namely its fixation and the likelihood of separation. Currently, thrombophlebitis is commonly referred to as thrombosis of the superficial veins, since inflammation is absolutely clearly defined. And phlebothrombosis is venous thrombosis of the vessels of the deep system. And again, we repeat that in both cases there may be a floating thrombus without signs of inflammation. In clinical practice, controversy and opposition between these two conditions also has negative consequences. The presence of thrombophlebitis of the saphenous veins should not be considered a mild pathology, since the spread of a blood clot to the deep system or the parallel independent occurrence of phlebothrombosis and thrombophlebitis pose a real danger of pulmonary embolism and death. Also important is the formation of a blood clot in the deep venous system with subsequent, in fact, disability of patients. Chronic venous insufficiency and postthrombophlebitic disease require regular, long-term and expensive treatment.

Hospitalization in a hospital, Elastic bandaging for at least 7-10 days around the clock, Non-steroidal anti-inflammatory drugs (NSAIDs - ketorol, ketonal, diclofenac, nimulide) initially parenterally, then in tablets, Phlebotropic drugs - detralex (venorus) up to 6 tablets in the first days, troxevasin , Local NSAIDs and heparin ointments, Antiplatelet agents - aspirin, pentoxifylline (trental), according to indications, anticoagulants - enoxaparin, nadroparin, dalteparin, warfarin, Exanta (melagatran/ximelagatran).

Localization or spread of a thrombus in the GSV at the level of the middle and upper third of the thigh. Localization of the thrombus in the SVC at the level of the popliteal fossa.

Hospital, operation for emergency indications - Ligation and intersection, respectively, of the GSV or SSV and tributaries at the point of entry into the femoral vein. Further treatment as in the previous paragraph.

spread of thrombosis through anastomosis or perforators to the deep venous system

Installation of a cava filter or plication or clipping of the inferior vena cava, thrombectomy from the main veins or from perforators, intersection and ligation of the GSV and SSV at the mouth.

Thrombophlebitis of deep veins

Emergency hospitalization, Bed rest

Bellera splint, Reopoliglyukin 400.0 + 5.0 trental,

troxevasin 1 cap x 4 times, aspirin ¼ tab x 4 times, heparins, installation of a cava filter, phlebotropic drugs and NSAIDs.

Additionally, it should be noted that to clarify the location of the thrombus, it is necessary to perform an ultrasound examination of the veins. Elastic bandages for phlebothrombosis should be applied with caution after ultrasound scanning. By squeezing the subcutaneous vein system, we either increase the blood volume by 20% in the deep system, or completely block the outflow of blood from the lower limb. In the first case, the likelihood of a blood clot breaking off increases; in the second, the clinical picture of acute phlebothrombosis is aggravated.

Thrombophlebitis of the saphenous veins

What is saphenous vein thrombophlebitis?

In fact, saphenous vein thrombophlebitis is a “double” disease. Because, firstly, the venous walls themselves become inflamed. And secondly, a blood clot forms in the vein - a thrombus.

Superficial thrombophlebitis in the vast majority of cases manifests itself as an acute disease.

Causes of thrombophlebitis of superficial veins

The cause of any thrombosis is a combination of three factors:

change in the configuration of the vein (for example, varicose transformation) and, as a result, “swirling” of blood in the lumen of the vessel;
“thickening” of the blood – a tendency (hereditary or acquired) to thrombosis;
damage to the vein wall (injection, trauma, etc.).

The main and most common cause of superficial thrombophlebitis is considered to be varicose veins. Also, the most common risk factors are:

genetic predisposition;
pregnancy and childbirth;
obesity, physical inactivity;
endocrine and oncological diseases.

Superficial thrombophlebitis: symptoms and manifestations

the appearance of “nodules” and compactions in the vein;
edema;
acute pain;
local increase in temperature;
change in skin color in the area of the inflamed vein.

Treatment of superficial thrombophlebitis

To treat thrombophlebitis of the superficial veins, different techniques and their combinations are used.

More often this may be conservative treatment:

compression therapy – wearing compression stockings, special elastic bandaging;
taking non-steroidal anti-inflammatory and painkillers;
locally, in the area of inflammation - cold;
according to indications - taking medications that “thin” the blood.

Purulent thrombophlebitis of the superficial veins: develops in patients with bacteremia that persists for >72 hours despite appropriate antibiotic therapy, especially in patients with an intravascular catheter. The most common etiological factors: Staphylococcus aureus, streptococci, gram-negative bacilli.

CLINICAL PICTURE AND NATURAL COURSE to top

Painful localized swelling with redness of the skin; in case of inflammation of varicose nodes, they are easy to palpate as a nodular or cord-like thickening. In the case of catheter-associated phlebitis of the superficial veins, symptoms appear in the area of the catheterized vein; it is impossible to draw blood from the catheter if a blood clot leads to its occlusion; sometimes the disease is asymptomatic (5–13%). With purulent thrombophlebitis of the superficial veins, there is additionally fever, severe redness, pain and the presence of purulent content at the site of the affected vessel.

Untreated illness goes away after a few days or weeks. Typically, after several months, the varicose veins undergo at least partial recanalization. In the case of phlebitis of the great saphenous vein of the lower extremity and the spread of thrombosis proximally, there is a risk of thrombosis transferring to the superficial femoral vein (namely proximal deep vein thrombosis). Phlebitis of the superficial veins is associated with a high risk of venous thromboembolic disease (VTEB). The incidence of coexistence of deep vein thrombosis and phlebitis of the superficial veins is highest in the case of damage to the proximal segment of the saphenous vein.

Diagnosed based on clinical symptoms; In cases of inflammation associated with the presence of a catheter/cannula in a vein, culture (usually the tip of the removed catheter) may reveal the etiological factor. In a limited form, especially associated with the presence of a catheter in the vessel or the action of irritating substances, diagnostic studies are not necessary. For inflammation of the veins (varicose veins) of the lower extremities, perform an ultrasound examination to localize the apex of the thrombus and determine the distance from the mouth of the deep vein system, since inflammation within the proximal portion of the great saphenous vein (above the knee joint) can spread to the deep vein system. In patients with migratory phlebitis without an obvious cause, conduct a detailed diagnosis to exclude cancer. In patients with phlebitis of a previously normal vein (non-varicose vein) in which the etiological factor is unknown, consider diagnostic work towards hypercoagulability or malignancy.

1. Catheter-associated phlebitis of the superficial veins: in the case of a short peripheral catheter, stop administering drugs through this catheter and remove it from the vein; in case of severe pain → NSAIDs (PO or topical; drugs →Table 16.12-1) or heparin (topically in the form of a gel) until symptoms go away, but not longer than 2 weeks.

The use of heparin in a therapeutic dose is not recommended, and antithrombotic prophylaxis (using heparin subcutaneously) is used in patients with an increased risk of venous thrombosis, for example. immobilized, after episodes of VTEB or with cancer →section. 2.33.3. Also consider anticoagulant treatment in patients with thrombosis of the proximal segment of the medial saphenous or lateral saphenous vein in whom symptoms of inflammation persist despite catheter removal. The duration of therapy depends on the clinical picture and ultrasound results.

Superficial vein thrombosis is not an indication for routine removal of a central catheter, especially if it is functioning normally.

2. Suppurative thrombophlebitis of superficial veins → remove the source of infection (eg catheter) and use antibiotic therapy, preferably targeted, and if ineffective, consider opening, draining or excision of a segment of the affected vein.

3. Superficial vein thrombosis: if it concerns a segment of the superficial vein of the lower limb ≥5 cm long → fondaparinux subcutaneously 2.5 mg/day. or low molecular weight heparin in a prophylactic dose (preparations → section 2.33.1, dosage → table 2.33-12) for ≥4 weeks. or a vitamin K antagonist (acenocoumarol or warfarin) at a dose maintaining an INR of 2–3 for 5 days with heparin, then on its own for 45 days. Anticoagulant treatment is also justified by: extensive thrombosis, thrombosis involving veins above the knee, especially near the saphenofemoral ostium, severe clinical symptoms, thrombosis involving the great saphenous vein, history of VTE or superficial vein thrombosis, active cancer, recent surgery.

In case of phlebitis of the great saphenous vein and extension of thrombosis proximally, due to the risk of transfer of thrombosis to the superficial femoral vein, refer the patient to a surgeon for the purpose of ligation of the great saphenous vein. There is no need to immobilize a patient with phlebitis of the superficial veins of the lower extremities, but unconditionally apply a multi-layer compression bandage made of an elastic bandage and use this treatment until the acute inflammatory process disappears. Once acute inflammation and swelling have resolved, consider appropriate compression socks or stockings.

Video (click to play).

Thrombosis of the superficial (subcutaneous) veins in clinical practice is referred to as “thrombophlebitis”. In the vast majority of cases, thrombophlebitis is a complication of chronic venous diseases that occur with varicose transformation of the saphenous veins (varicothrombophlebitis).
Clinical signs:
. pain along the thrombosed veins, limiting limb movements;
. a stripe of hyperemia in the projection of the affected vein;
. on palpation - a cord-like, dense, sharply painful cord;
. local increase in temperature, hyperesthesia of the skin.
When examining a patient with suspected thrombophlebitis, it is necessary to examine both lower extremities, since bilateral combined damage to both superficial and deep veins is possible. In addition to identifying symptoms of thrombophlebitis in patients suspected of having this disease, it is necessary to specifically determine the presence of symptoms indicating PE. The value of a physical examination for accurately establishing the extent of thrombosis is low due to the fact that the true prevalence of saphenous vein thrombosis is often 15-20 cm higher than clinically detectable signs of thrombophlebitis. In a significant proportion of patients, the transition of the thrombotic process to the deep venous lines is asymptomatic. The main diagnostic method is compression ultrasound duplex angioscanning. The standard scope of ultrasound angioscanning must necessarily include examination of the superficial and deep veins of not only the affected, but also the contralateral limb to exclude simultaneous thrombosis, which is often asymptomatic. The deep veins of both lower extremities are examined along their entire length, starting from the distal parts of the leg to the level of the inguinal ligament, and if intestinal gas does not interfere, then the vessels of the iliocaval segment are examined.

Indications for hospitalization
— localization of acute thrombophlebitis on the thigh;
— localization of acute thrombophlebitis in the upper third of the leg with damage to the small saphenous vein.
Such patients should be hospitalized in vascular surgery departments. If this is not possible, hospitalization in a general surgical hospital is acceptable.
Treatment tactics
In case of thrombosis of superficial veins against the background of varicose veins, a more active surgical tactic seems appropriate.

Conservative treatment should include the following main components:
1) active mode;
2) elastic compression of the lower extremities;
3) local therapeutic effect on the affected limb (cold, drugs containing heparin and/or
NSAIDs).

4) systemic pharmacotherapy.

In case of spontaneous thrombosis of the superficial veins of the lower extremities, subcutaneous administration of fondaparinux sodium or prophylactic (or possibly intermediate) 1
doses of LMWH for at least 1.5 months. New oral anticoagulants (NOACs) (apixaban, dabigatran etexilate, rivaroxaban) should not be used for the treatment of saphenous vein thrombosis due to the current lack of data confirming their effectiveness and safety in this pathology. In addition to anticoagulants, in case of severe pain, it is possible to use non-steroidal anti-inflammatory drugs (NSAIDs) orally for 7-10 days. It should be taken into account that their combination with
anticoagulants increases the likelihood of hemorrhagic complications. Intermediate doses include LMWH doses that are 50-75% of the therapeutic dose. It is not advisable to use antibacterial drugs in the complex treatment of superficial vein thrombophlebitis in the absence of signs of a systemic inflammatory reaction.
Surgical treatment:
1. Crossectomy (Troyanov-Trendelenburg operation). High (immediately at the deep main) ligation of the large (or small) saphenous vein with mandatory ligation of all estuarine tributaries and excision of the trunk of the saphenous vein within the surgical wound. Indicated when thrombophlebitis spreads to the upper half of the thigh or estuarine tributaries when v. is affected. saphena magna and the upper third of the leg when affected v. saphena parva. The operation is feasible in any category of patients.
2. Thrombectomy from the main deep veins. Performed when thrombosis spreads beyond the sapheno-femoral or sapheno-popliteal ostium. The choice of access and thrombectomy method is determined by the level of location of the proximal part of the thrombus. After the anastomosis is released, a crossectomy is performed.
4. Miniphlebectomy in the pool v. saphena magna and/or v. saphena parva. Provides for the removal of all varicose veins (thrombosed and non-thrombosed) after crossectomy. It can be performed in uncomplicated patients in the first 2 weeks of the disease. At a later date, a dense inflammatory infiltrate in the area of varicothrombosis-lebitis prevents atraumatic removal of the affected veins.

5. Puncture thrombectomy from thrombosed nodes of the saphenous veins. Performed against the background of severe periphlebitis. Removal of blood clots from the affected veins under conditions of adequate postoperative elastic compression leads to a rapid reduction in pain and aseptic inflammation. Surgical treatment must be combined with the appropriate use of anticoagulants.
Diagnosis and treatment of post-injection thrombosis of the saphenous veins of the upper extremities
Clinical manifestations are similar to those of thrombosis of the saphenous veins of the lower extremities:
- pain along the course of thrombosed veins;
- a stripe of hyperemia in the projection of the affected vein;
- on palpation - a cord-like, dense, sharply painful cord;
- local increase in temperature.
No special diagnostic methods are required.

Therapeutic tactics are conservative treatment only:
— local therapeutic effect on the affected limb (cold, drugs containing heparin and/or NSAIDs);
- in case of severe pain, it is possible to use NSAIDs orally for 7-10 days;
— the use of anticoagulants is advisable only when the thrombotic process progresses and there is a threat of its spread to the subclavian vein.
Diagnosis of DVT
The formation of a blood clot can begin in any part of the venous system, but most often in the deep veins of the leg. There are occlusive and non-occlusive thrombus. Among non-occlusive thrombi, floating thrombi, which can cause pulmonary embolism, are of greatest practical interest. The degree of embolism of venous thrombosis is determined by the characteristics of the clinical situation. The decision about the degree of potential threat to the patient’s life is made by the attending physician based on a comprehensive assessment of the patient’s somatic status, characteristics of the thrombotic process and ultrasound angioscanning data. In this case, one should take into account the time of occurrence and localization of the thrombus, its nature (mobility in the lumen of the vein), the volume of the moving part and the diameter of the base. Embolic-dangerous thrombi are located in the femoral, iliac and inferior vena cava, the length of their moving part is usually at least 7 cm. However, in patients with low cardiopulmonary reserve due to concomitant pathology or previous pulmonary embolism, there is a real threat of life-threatening embolism. pain may represent floating thrombi of smaller sizes.
Clinical manifestations depend on the localization of thrombosis, the prevalence and nature of damage to the venous bed, as well as the duration of the disease. In the initial period, with non-occlusive forms, clinical symptoms are not expressed or are completely absent. Sometimes the first sign of DVT may be symptoms of pulmonary embolism.
The typical spectrum of symptoms includes:
. swelling of the entire limb or part thereof;
. cyanosis of the skin and increased pattern of subcutaneous veins;
. bursting pain in the limb;
. pain along the neurovascular bundle.
For clinical diagnosis, the Wells index (Table 4) can be used, reflecting the likelihood that the patient has DVT of the lower extremities. Based on the sum of points scored, patients are divided into groups with low, medium and high probability of having venous thrombosis.
Deep vein thrombosis in the superior vena cava system is characterized by:
. swelling of the upper limb;
. swelling of the face, neck;
. cyanosis of the skin and increased pattern of the saphenous veins;
. bursting pain in the limb.
Since clinical data do not allow us to judge with certainty the presence or absence of DVT, the diagnostic search should include subsequent laboratory and instrumental testing. examination.

Laboratory diagnostics
Determination of the level of D-dimer in the blood. An increased level of D-dimer in the blood indicates actively occurring thrombus formation processes, but does not allow one to judge the location of the thrombus. The highest sensitivity (more than 95%) is provided by quantitative methods based on enzyme-linked immunosorbent assay (ELISA) or immunofluorescent assay (ELFA). After the development of thrombosis, the D-dimer gradually decreases and after 1-2 weeks can return to normal. Along with high sensitivity, the test has low specificity. Elevated levels of D-dimer are detected in many conditions, including tumors, inflammation, infection, necrosis, after surgery, during pregnancy, as well as in the elderly and patients in hospital. The upper limit of normal for D-dimer, determined by enzyme-linked immunosorbent methods, in persons under 50 years of age is 500 μg/l; in older age groups it is recommended to calculate it using the formula: age × 10 µg/l.

In connection with the described features, the following algorithm for using the D-dimer indicator for diagnosing DVT is proposed:

- patients without any clinical signs suggesting the presence of DVT should not have their D-dimer level determined for screening purposes;
— patients with clinical symptoms and anamnesis that leave no doubt about the presence of DVT should not have their D-dimer level determined;
— patients with clinical signs that suggest DVT, if it is not possible to perform compression ultrasound angioscanning in the next few hours, should determine the D-dimer level.

An increase in the indicator indicates the need for an ultrasound examination. If the medical institution does not have ultrasound equipment, the patient should be referred to another clinic with appropriate capabilities. In cases where the level of D-dimer in the blood is not elevated, the diagnosis of DVT can be rejected with a high degree of probability.

Instrumental diagnostics
Ultrasound compression duplex angioscanning is the main method of examination for suspected venous thrombosis. The mandatory scope of the study includes examination of the saphenous and deep veins of both lower extremities, since there is a possibility of contralateral thrombosis, which often occurs asymptomatically. If the patient has symptoms of pulmonary embolism and there are no ultrasound signs of DVT in the main veins of the extremities, pelvis, and IVC, the gonadal, hepatic, and renal veins should be examined. An active search for DVT using ultrasound angioscanning seems appropriate in the preoperative period in patients at high risk of VTEC, as well as in cancer patients. In these same patients, it is advisable to conduct ultrasound angioscanning for screening purposes after surgery. When thrombosis spreads to the iliocaval segment, if it is impossible to determine its proximal border and nature according to duplex ultrasound scanning, radiopaque retrograde iliocavography or spiral computed tomography (CT) is indicated. During angiography, a number of therapeutic manipulations are possible: implantation of a vena cava filter, catheter thrombectomy, etc.