REVI EW ARTI CLE
Supe r ficia l t hr om bophle bit is: e pide m iology, physiopa t hology, dia gnosis
a nd t r e a t m e nt
M a rcone Lim a Sobr e ir aI; W inst on Bonnet i YoshidaI I; Sidnei La st ór iaI I I
IAssistant physician. PhD, Vascular Surgery, Universidade Estadual Paulista (UNESP), Botucatu, SP,
Brazil.
IIProfessor, Vascular Surgery, UNESP, Botucatu, SP, Brazil.
IIIAssistant professor, PhD, Vascular Surgery, UNESP, Botucatu, SP, Brazil.
Correspondence
J Vasc Bras. 2008;7(2):131-143.
ABSTRACT
Superficial thrombophlebitis of the lower limbs is a commonly occurring disease, and it is associated with various clinical and surgical conditions. Historically considered to be a benign disease due to its superficial location and easy diagnosis, its treatment was, for a long time, conservative in most cases. Nevertheless, recent reports of high frequency and associated thromboembolic complications, which vary from 22 to 37% for deep venous thrombosis and up to 33% for pulmonary embolism, have indicated the need for broader diagnostic and therapeutic approaches in order to diagnose and treat such possible complications. The possibility of coexistence of these and other systemic
disorders (collagenosis, neoplasia, thrombophilia) interferes with evaluation and influences therapeutic conduct, which may be clinical, surgical or combined. However, due to a lack of controlled clinical assays as well as to a series of uncertainties regarding its natural history, the diagnosis and treatment of superficial thrombophlebitis remain undefined. A literature review was performed analyzing the epidemiology, physiopathology and current status of the diagnosis and treatment of superficial thrombophlebitis.
Keyw ords: Pulmonary embolism, prevention and control, thrombophlebitis, superficial thrombophlebitis, deep venous thrombosis.
RESUM O
A tromboflebite superficial de membros inferiores € doen•a de ocorr‚ncia comum, estando associada a diversas condi•ƒes cl„nicas e cir…rgicas. Historicamente considerada doen•a benigna, devido † sua localiza•‡o superficial e ao fˆcil diagn‰stico, o tratamento foi conservador durante muito tempo, na maioria dos casos. Entretanto, relatos recentes de freqŠ‚ncias altas de complica•ƒes
de out ras desordens sist êm icas ( colagenoses, neoplasias, t rom bofilias) int erfere na avaliação e influencia a condut a t erapêut ica, que pode ser clínica, cirúrgica ou com binada. No ent ant o, devido à falt a de ensaios clínicos cont rolados e às incert ezas quant o a sua hist ória nat ural, o diagnóst ico e o t rat am ent o da t rom boflebit e superficial cont inuam indefinidos. Nest e t rabalho, foi feit a um a revisão da lit erat ura analisando-se a epidem iologia, fisiopat ologia e est ado at ual do diagnóst ico e
t rat am ent o da t rom boflebit e superficial.
Pa la vra s- cha ve: Em bolia pulm onar, profilaxia, t rom boflebit e, t rom boflebit e superficial, t rom bose venosa profunda.
I nt r oduct ion
Superficial t hrom bophlebit is ( ST) , also called superficial venous t hrom bosis, is a pat hological condit ion charact erized by presence of a t hrom bus in t he lum en of a superficial vein, followed by inflam m at ory react ion of it s wall and adj acent t issues. I t present s wit h a palpable, hot , painful and hyperem ic cord t hrough a superficial vein.1 This t hrom bosis has variable am plit ude, reaching from
sm all t ribut aries unt il large ext ension of saphenous t runks in t he lower lim bs. I n m ore severe cases, it can be ext ended t o t he deep venous syst em ( DVS) ;2 - 4 it can also cause pulm onary em bolism ,2 , 5
and t here are indicat ions of an associat ion wit h recurrent episodes of venous t hrom boem bolism .6
The incidence of ST ranges bet ween 125,000 cases/ year ( USA) and 253,000 cases/ year ( France) , and is m ore frequent when m ore accurat e diagnost ic m et hods are used, such as duplex scan
( DS) .7 , 8 I n our count ry, Von Rist ow et al., in a ret rospect ive survey of pat ient s subm it t ed t o varicose
vein surgery, found signs of previous t hrom bophlebit is in 16% of cases.9
Physiopa t hology
ST physiopat hology, sim ilarly t o deep venous t hrom bosis ( DVT) , is also relat ed t o Virchow's t riad ( 1856) . ST m ore frequent ly occurs in varicose veins, since t hey can have m orphological changes in t heir wall t hat predispose t o st asis, and consequent ly t o t he developm ent of t he t hrom bot ic
process.1 0 A large num ber of ST cases is secondary t o chem ical int im al lesion, by inj ect ions of
infusions of different solut ions, wit h diagnost ic or t herapeut ic purposes, and/ or m echanical lesions, such as, for exam ple, venous cat het erizat ion. ST can be prodrom ic of several known syst em ic diseases, such as neoplasm s, art eriopat hies and collagenosis,1 1 - 1 3 in addit ion t o following a series of ot her disease and syndrom es:
- Troussea u's syndrom e: charact erized by episodes of recurrent superficial m igrat ory
t hrom bophlebit is wit h im pairm ent of veins, bot h in t he upper and lower lim bs, associat ed wit h m ucin- producing adenocarcinom as of t he gast roint est inal t ract ( st om ach, pancreas and colon) , lung, breast , ovary, and prost at e.1 4
- M ondor's dise a se : t hrom bophlebit is of rare occurrence, m ore frequent in t he fem ale populat ion and affect ing t he veins of t he ant erolat eral t horacic wall. Most of t he t im es, it s et iology is unknown. I n som e cases, it is associat ed wit h local t raum a, use of oral cont racept ives, prot ein C deficiency, and presence of ant icardiolipin ant ibodies.1 5 Farrow et al. observed an associat ion wit h breast
- Lem ierre's syndrom e:described for the first time in 1936, it is characterized by septic
thrombophlebitis of the internal jugular vein concomitant to oropharynx infection, and may progress with metastases, especially for the pulmonary territory, but also liver and spleen. Other causes
related to its occurrence are central venous catheterization and infection of other cervical sites.17,18
The most prevalent etiologic agent is the gram-negative anaerobic germ Fusobact erium
necrophorum19.
- Buerger's disea se ( Throm boa ngiit is oblit era ns) : in this case, ST has a migratory character
and may precede or be concomitant with arterial impairment.20 Its presence reinforces diagnostic of
Buerger's disease.
Pa t hology
From the histopathological perspective, vein and thrombus in ST, in its initial stage, have
predominance of leukocyte infiltrate (flogistic) (Figure 1– HP blade), and this inflammatory process
is extended to neighboring tissues, especially skin and subcutaneous cell tissue, thus explaining
characterization of its clinical status, as well as less friability and more thrombus consistency.21
Topogr a phic a spe ct s
In general, the left lower limb (LLL) seems to be more affected than the right lower limb (RLL). Upper limb veins are also often affected, as a complication of venous catheterization, and are found
in up to 51.5% of cases in a survey conducted in our institution22; the cephalic and basilic veins are
the most frequently affected.23
In a retrospective survey, performed by Lutter et al., of 1,143 confirmatory DS for ST, 56%
occurred in the LLL, whereas 51% in the RLL. However, such difference was not significant.24 Gillet
vein t errit ory ( 24.3% ) , and in 0.7% ( t wo cases) bot h t errit ories were involved.2 5
Thr om boe m bolic com plica t ions
Deep ve nous t hr om bosis
Since 1964 report s have been published on t his com plicat ion in pat ient s wit h ST.1 0 , 2 6 - 2 8 I t is est im at ed t hat t he occurrence of a spont aneous episode of ST increases in about 10 t im es ( odds rat io = 10.3; 95% CI : 2.0- 51.6) t he risk of developing DVT over t he 6 subsequent m ont hs and absolut e risk of 2.7% when com pared wit h a populat ion t hat never had a previous episode of ST.2 9
Sim ult aneous im pairm ent of DVS usually occurs due t o t hrom bus ext ension t hrough t he perforat ing veins or aort ic arch, but it is possible t hat t here is a given anat om ical connect ion ( associat ed DVT) , st rengt hening t he possible condit ion of hypercoagulabilit y following ST. However, ext ension of t he t hrom bus int o t he superficial venous syst em and/ or it s proxim it y t o t he DVS had no significant correlat ion wit h DVT occurrence according t o som e aut hors.3 0 , 3 1 I n m any series, t he frequency of
associat ion bet ween ST and DVT ranged bet ween 22.7 and 36% .3 , 1 0 , 2 4 , 3 2 This associat ion also
seem s t o be m ore frequent in pat ient s wit h varicose veins, probably due t o t he m orphological
changes t hat are charact erist ic of t his disease, which favor bot h st asis and bidirect ional blood flow in perforat ing veins and arches.3 3 However, in a st udy conduct ed in our service,3 4 t he absence of
varicose veins increased m ore t han nine-fold t he chances of an individual having DVT ( odds rat io = 9.09; 95% CI : 1.75- 50.0) , a fact t hat was seen by ot her aut hors, who showed t hat presence of varicose veins was relat ed t o
a m ore benign evolut ion of venous t hrom boem bolic disease.3 0 I n t he st udy by Gillet et al., DVT was diagnosed in 36.4% of cases when t he affect ed vein was a varicose vein, and in 8.3% when t he affect ed vein was not a varicose vein. However, alt hough t he absolut e difference in frequencies was relevant , it was not significant ( p = 0.097) , which m ay be explained, according t o t he aut hors, by t he ext ension m echanism of ST int o t he DVS t hrough t he perforat ing veins, which are m ore developed and m ore frequent ly insufficient in pat ient s wit h varicose veins. Presence of
t hrom bophilia changes occurred in 14.9% of pat ient s in t he group wit h varicose veins, and in 50% in t he group wit hout varicose veins.2 5 On t he ot her hand, Bounam eaux et al., in a ret rospect ive
survey (6- year period) , in which plet hysm ography associat ed wit h cont inuous-wave Doppler
ult rasound and DS were used as diagnost ic m et hods for DVT, account ed for 551 confirm ed cases of ST, and 31 of t hem ( 5.6% ) had sim ult aneous DVT when ST was diagnosed, and in 26 of t hese DVT was proxim al ( 4.7% ) . I n t his sam ple, t he only variable t hat had st at ist ical relevance ( p < 0.02) for sim ult aneous occurrence of DVT and ST was previous im m obilizat ion.3 5 I n an original st udy, out of
60 pat ient s wit h ST, 13 ( 21.7% ) had associat ed DVT.3 4
Pulm ona ry em bolism
The associat ion bet ween ST and episodes of pulm onary em bolism ( PE) , whet her or not sym pt om at ic, has also been report ed by m any aut hors, and it s frequency ranged from 3 t o
33% .4 , 5 , 1 3 , 2 5 On t he ot her hand, Weert et al., in a ret rospect ive cohort st udy, showed t hat , over a
6- m ont h period, occurrence of ST was not a predict ive fact or for PE occurrence ( odds rat io = 1.0; 95% CI : 0,07- 15,0) .2 9 However, in a ret rospect ive series, Blum em berg et al. dem onst rat ed t hat
t hrom bosis diagnosed by DS progressed t o t he DVS in 8.6% of cases, and in 10% of t hese t here was PE, invest igat ed using scint igraphy.4 Verlat o et al., in a prospect ive st udy, found high frequency
of PE using scint igraphy ( 33.3% ) in pat ient s who had ST as t he only em boligenic source.5 Throm bus
proxim it y wit h t he DVS ( especially represent ed by arches) and t he concom it ant im pairm ent of t hese j unct ions ( saphenofem oral and/ or saphenopoplit eal) did not show significant correlat ion wit h
t hat being older t han 60 years of age, hist ory of DVT, prolonged rest , bilat eral ST, m ale gender, and presence of infect ions were m ore frequent ly associat ed wit h DVT or PE.2 4 I n t he original st udy we
perform ed, t here was a 28.3% frequency of PE associat ed wit h ST, and t he sim ult aneous presence of DVT was not a det erm inant for it s occurrence ( p = 0.36) .3 4
D ia gnosis
Unt il t he lat e 1980's, ST was considered as a benign disease, self- lim it ed, wit h low m orbidit y and low pot ent ial for com plicat ions, and it s t reat m ent was sym pt om at ic. However, m ore recent publicat ions showing high frequencies of PTE associat ed wit h ST have changed t hat focus, wit h subsequent changes in diagnost ic and t herapeut ic approaches.3 - 6 , 1 0 - 1 2 , 2 5 , 3 6 - 3 8
Diagnosis should be perform ed carefully, wit h det ailed clinical hist ory, paying special at t ent ion t o possible risk fact ors and occurrence of previous t hrom boem bolic event s: hist ory of weight loss ( neoplasm s) , sm oking, infect ion ( Lem ierre's syndrom e) , am ong ot hers.
Risk fact ors are t he sam e for DVT, i.e., clinical or surgical condit ions relat ed t o Virchow's t riad, which m ay occur alone or com bined, enhancing t he pot ent ial, facilit at ing and/ or t riggering developm ent of ST. The following are som e exam ples:
- Endot helium lesion: int ravenous inj ect ions, venous cat het erizat ion, t raum a, infect ions;
- Flow changes: varicose veins, im m obilizat ion.
- Coagulat ion changes: neoplasm s, pregnancy, t hrom bophilia, infect ion.
Physical exam inat ion should explore t opographic diagnosis accurat ely (Figure 2) , det erm ining t he affect ed venous t runk and it s ext ension/ concom it ance for t he DVS, which can det erm ine change in t herapeut ic approach.3 9 Som e aut hors support t he syst em at ic use of DS in pat ient s wit h lower lim b
edem a, in cases wit h previous hist ory of ST, since ST has a high predict ive value for DVT, especially in t he 6 subsequent m ont hs aft er it s first episode.2 9 Anot her advant age of DS is t he possibilit y of
est ablishing a different ial diagnosis wit h ot her pat hologies, such as lym phangit is.
t he superficial venous syst em and it s proxim it y relat ionship wit h t he DVS (Figure 3) , as well as ext ension or sim ult aneous im pairm ent of t he DVS.4 0 For t hese reasons, it s rout ine use is support ed
by several aut hors.3 , 2 4 , 2 8 , 3 9 , 4 0 Pat ient s wit h clinical and ult rasound diagnosis of ST have an easily
visible and non- com pressible echogenic t hrom bus at DS.4 0
DS is part icularly useful in t he different ial diagnosis of cellulit is, eryt hem a nodosum , panniculit is and lym phangit is, accurat ely assessing whet her t here is DVS im pairm ent and it s ext ension.4 0 I n
addit ion, it has t he advant age of being an innocuous and noninvasive m et hod, opposed t o phlebography, which has com plicat ions such as cont rast allergy, exposure t o radiat ion and propagat ion of t hrom bosis,4 0; no reference was found as t o use of phlebography in ST diagnosis.
Tr e a t m e nt
Sim ilarly t o t he diagnost ic approach, t reat m ent of ST has not been est ablished due t o lack of
cont rolled clinical t rials and t o a num ber of uncert aint ies as t o it s nat ural hist ory, which generat es a range of t herapeut ic opt ions. The t reat m ent depends on it s et iology, ext ension, sym pt om severit y, and associat ion wit h ot her t hrom boem bolic phenom ena, such as DVT and/ or PE.2 - 4 The possibilit y of a coexist ence of t hese and ot her syst em ic disorders int erferes wit h t he assessm ent and influences t herapeut ic conduct , which m ay be clinical, surgical or com bined.
Clinica l t r e a t m e nt
stasis and increase venous flow velocity.41 Among these measures, walking and rest in the
Trendelenburg position are the most common and most widely accepted. During walking, there is activation of calf and plantar pumps, favoring increase in flow velocity and possibly a higher activity
of the fibrinolytic system.41 Rest in the Trendelenburg position also favors venous return due to
gravitational drainage, which can increase fibrinolytic activity.
Elastic compression, despite being widespread, is not consensual. Andreozzi et al. support the use of medium to high compression elastic band in the acute stage of the disease, interposing gauze with zinc oxide between the skin and the band, which seems to reduce the flogistic process; elastic
stockings represent the form of maintenance treatment.21 De Palma indicates the use of elastic
stockings associated with aspirin in cases of varicose vein with thrombophlebitis, as long as this impairment is away from saphenous trunks, and patients are advised to maintain their daily
activities.39 In a prospective, randomized and controlled study comparing varied treatment forms of
ST (elastic stockings, surgery, heparin and oral anticoagulation), elastic stockings were the
therapeutic option that had the lowest cost, but it was associated with higher frequency of thrombus
extension and higher social cost due to time of work leave and/or inactivity.42 In addition,
compression with elastic stockings in acute ST stage may worsen local pain, and theoretically cause embolization of a more friable thrombus segment from the vein affected by ST.
Existence of flogistic signs and symptoms in ST suggests indication of anti-inflammatory drugs (systemic or topic); however, there is no evidence of their efficacy. Application of wet heat, such as warm compresses and thermal bags, seems to have an anti-inflammatory action and is commonly
used. Becherucci et al.,43 in a controlled series of 120 patients with thrombophlebitis associated with
drug infusion, compared the efficacy of three different treatments:
-Group 1: diclofenac gel;
-Group 2: oral diclofenac 75 mg twice a day;
-Group 3: placebo.
Symptomatic relief in 48 hours of treatment was better in groups 1 and 2 in relation to placebo.43
However, in this study, the outcome was relief of symptoms, which is subjective. DS should have been used to assess thrombus extension and other more objective parameters.
In another prospective and randomized series, which included 68 patients with spontaneous ST or related to drug infusion, piroxicam gel was compared to a placebo and there was no significant
difference between both groups.44 This result corroborated an experimental study conducted at our
institution, showing no benefits in use of anti-inflammatory ointments or heparinoids in the course
of local pathological process, seen at optical microscopy.45
According to recommendations of the American College of Chest Physicians (ACCP), patients with ST secondary to drug infusion can benefit from use of diclofenac gel (degree 1B) or oral diclofenac
(degree 2B), and there is no mention to spontaneous ST or associated with varicose veins.46
However, the series used to support this proposal are small and have outcomes based on subjective
parameters.43,44
On the other hand, anticoagulants, either in prophylactic or therapeutic doses, are the class of drugs that seem to have the highest number of benefits for the patient, since they act on the core of the disease physiopathology – clot formation and propagation. They can be used as the only therapeutic option or as an adjuvant in surgical treatment. In addition to the obvious thrombotic effect,
anticoagulants, especially heparins, have anti-inflammatory activities that enhance the potential of
Although some characteristics of the disease behavior, such as its occurrence in a non-varicose venous territory or the thrombus proximity relationship with the DVS, are suggestive of a
non-benign course followed by PTE, there is still no evidence of this hypothesis.3,25,48,49Ascer et al., in a
prospective study, suggested that anticoagulant therapy could prevent recurrence and pulmonary
embolism;28 therefore, it is the ideal treatment for ST, especially when it reached the
saphenofemoral junction (SFJ). Most series on anticoagulant treatment of ST with
heparin1,3,25,36,39,50,51 use unfractioned heparin (UFH) or low-molecular-weight heparin (LMWH) as
an initial choice of drug for the treatment.
Heparin dose (UFH or LMWH) is also controversial; some series compared different heparin doses between themselves and to others with alternative therapeutic modalities, such as
anti-inflammatory drugs. There seems to be a trend of favorable response when higher heparin doses are used (when compared with prophylactic doses). In a multi-center and randomized study, 117 patients were divided into three groups: I) nadroparin calcium – fixed prophylactic dose; II) nadroparin calcium – weight-corrected dose; and III) naproxen (AINH). By the end of 6 days, symptomatic relief was significantly higher in groups I and II than in the group using anti-inflammatory (p < 0.001). There was no difference in efficacy between the two groups using
nadroparin.50 In another series with a similar design, comparing enoxaparin sodium with
anti-inflammatory and placebo, there was no significant difference as to DVT incidence between both groups after 12 days of treatment. However, the incidence of symptomatic venous
thromboembolism was significantly higher in groups using enoxaparin (p < 0.001), and this
protection was maintained until the first 3 months of treatment.52
High UFH doses were compared to prophylactic doses in a randomized series of 60 patients diagnosed with GSV proximal ST. There was significant difference in favor of high heparin doses regarding occurrence of symptomatic and asymptomatic thromboembolic events by the end of a
6-month follow-up (Table 1).51
In a prospective, double-blind and randomized study, 436 patients with ST were divided into four groups:
-Group 1: enoxaparin 40 mg day + elastic stockings;
-Group 2: enoxaparin 1.5 mg/kg/day + elastic stockings;
-Group 3: oral tenoxicam 20 mg/day + elastic stockings;
-Group 4 (control): only elastic stockings (control).
prescribed for 10 days and the patients were followed for 3 months (clinical and ultrasound
assessment). Over the first 12 days, the patients using enoxaparin (groups 1 and 2) or tenoxicam (group 3) had significant reduction in disease progression (thrombus extension) compared with those who exclusively used elastic stockings, and there was no difference between both enoxaparin groups. When enoxaparin and tenoxicam were compared, there was a favorable trend
(nonsignificant) in terms of benefits for the enoxaparin. In terms of thromboembolic events, there was no trend of a favorable result in the three groups that had drug treatment, with no significant difference between them when compared with the control group. By the end of the study period (3
months), that trend disappeared (Table 2), suggesting evidence of a rebound effect or of an
unknown trait of ST natural history. It was not possible to reach a conclusion as to the best
therapeutic option for this disease in this study.53
Heparin can also be found in gel for topic use; however, despite supported by some authors,54-57its
safety and efficacy have not been properly confirmed. G‰rski et al. proposed application of
micronized and encapsulated gel heparin – in the form of slow-release spray (Lipohep Forte
Spraygel) – for symptomatic relief in ST.55 However, there was no conclusion as to prophylaxis of
thromboembolic complications, since this was not the objective of the study.
With regard to the antivitamin K oral anticoagulant, only one prospective and randomized study compared it to other therapeutic modalities (elastic stockings, UFH, LMWH, surgery), and found no significant difference as to complications (thrombus extension, DVT). However, it represented a
therapeutic option of high social cost compared with the others as a consequence of work leave.42
Sur gica l t rea t m ent
Surgical treatment is also controversial. The possible advantages of surgery are faster symptomatic
relief and shorter hospital stay, which could reduce costs.58 On the other hand, its disadvantage is
indications will depend on thrombus location within the superficial venous system (its proximity relationship with the DVS), existence of favorable technical and clinical condition.
Surgical treatment is more indicated for ST affecting varicose veins. In cases of thrombophilia and neoplasms – and, therefore, with higher thromboemboligenic risk – treatment with anticoagulants is the best alternative.
Surgical treatment basically has three objectives:
-Avoiding thrombosis extension from the superficial to the deep venous system;
-Treating superficial venous insufficiency, likely to be the cause of ST;
-Preventing recurrences.
The surgical techniques that can be used are crossectomy at the SFJ level or saphenopopliteal junction and ligation of perforating veins to avoid thrombus extension for the DVS and removal of segments with thrombus. The main complication of this treatment is postoperative hematoma, more frequent than in elective varicose vein surgery, due to the inflammatory component and to
adherence to adjacent tissues.
In some situations, the thrombus can extend proximally beyond the site where it is palpable or
visible by inflammatory signs, enhancing the potential risk of thromboembolic complications.
3,27,59-61 For some authors, SFJ involvement is an indication of surgical treatment.27,58
A retrospective series27 assessed 221 patients, who were divided into four treatment groups:
-Local heat + systemic anti-inflammatory drugs;
-Anticoagulant therapy;
-Surgery + anticoagulation;
-Surgery.
Surgical treatment, (ligation + segment removal), in addition to bringing faster symptomatic relief, definitively treated the disease, since it eliminated the possibility of recurrences and reduced
hospital stay and its cost, although such difference was not significant.27
However, all cases of PE occurred in group A, whereas DVT was observed only in group D27 (Table
This series only evaluat ed cases of ST in pat ient s wit h varicose veins, which m ay be a bias, since t he int rinsic m orphological change in t hese venous t runks can account for occurrence of ST,
different ly from what occurs when t he disease is present in pat ient s wit hout varicose disease, when a hypercoagulabilit y condit ion can be t he det erm ining fact or and is not being t reat ed by surgery.
Many aut hors consider t he SFJ involvem ent as an absolut e indicat ion for surgery.5 8 , 5 9 , 6 1 I n a
ret rospect ive series, Lohr et al. assessed 43 cases of ST affect ing t he SFJ t hat were t reat ed wit h saphenous vein st ripping or SFJ ligat ion, and aft er a 4- m ont h follow- up, t here was no progression of t he t hrom bus neit her PE. The aut hors also assessed t he cost s for each t ype of t herapeut ic approach and found t hat , when t he clinical t reat m ent ( ant icoagulat ion) was chosen, t he cost was US$
7,967.62. When t he surgical t reat m ent was indicat ed, t here was a reduct ion of nearly 40% ( US$ 4,831.11) of t he t ot al cost , and t he pat ient s subm it t ed t o surgery ret urned fast er t o t heir everyday act ivit ies.5 8
Low m orbidit y rat e of t he surgical procedure should also be considered. I n cases of SFJ ligat ion, it can be perform ed under local anest hesia in m ost pat ient s, reducing hospit al st ay and cost .6 1
I n a syst em at ic review art icle on t he t reat m ent of supragenicular ST wit hout DVS involvem ent , Sullivan et al. claim ed t hat surgery ( SFJ ligat ion + rem oval of phlebit ic segm ent s + int errupt ion of perforat ing veins) produces bet t er result s when com pared wit h ant icoagulat ion in t erm s of t hrom bus ext ension, recovery t im e, bleeding, and sym pt om at ic relief. However, it does not prevent
t hrom boem bolic com plicat ions and has higher m orbidit y rat es.6 2
I n sit uat ions in which ST occurs in varicose veins, t he benefit s of surgery are clear, since it can repair possible causes, m inim izing risk of recurrences. Nevert heless, when it occurs in non- varicose veins, t his prot ect ive effect m ay not be present , j ust ifying, t o som e aut hors, t he opt ion for t he clinical t reat m ent or it s associat ion wit h t he surgical t reat m ent , bot h before and aft er t he surgery.3 -5 , 2 7 , 2 8 , 6 1
There was no difference as t o DVT incidence bet ween t he groups of t reat m ent ( p > 0.05) , but t he incidence of t hrom bus ext ension was significant ly higher in groups of elast ic com pression and sim ple ligat ion ( p < 0.05) . The m ost expensive t reat m ent was t hat using LMWH, and t he cheapest was wit h elast ic com pression,4 2 alt hough it had t he highest social cost ( t im e and cost due t o inact ivit y) . On
t he ot her hand, it should be considered t hat , in t his st udy, only pat ient s wit h varicose veins were assessed. Ant icoagulant dose and durat ion of ant icoagulat ion were not m ent ioned, and t he ult rasound perform ed during follow- up was not blinded, which is a favorable bias t o t he group subm it t ed t o surgery. I n anot her prospect ive and consecut ive series, whose obj ect ive was evaluat ing safet y, efficacy and cost of clinical t reat m ent using LMWH com pared wit h surgery ( saphenofem oral disconnect ion) , t here were no significant differences bet ween bot h groups as t o com plicat ions, ST recurrence and incidence of new episodes of DVT and PE.6 3
Conclusion
Based on clinical hist ory dat a, physical exam inat ion and DS, t reat m ent of ST can be clinical, surgical or bot h. I t is necessary t o est ablish whet her t he episode occurs in varicose veins or in non- varicose veins; whet her t he event was preceded by a t riggering fact or; which level t he t hrom bus is locat ed wit hin saphenous t runks; and which it s proxim it y wit h t he DVS is. These t wo lat t er are dependent on ult rasound findings.
Lit erat ure dat a suggest t hat , in case t he event occurs in non- varicose veins and wit h no apparent t riggering fact or, it is only necessary t o search for ot her changes, such as neoplasm s or
t hrom bophilias. I t is necessary t o m aint ain t he pat ient ant icoagulat ed for a variable period of t im e, depending on disease ext ension. I n case t he t hrom bosis is rest rict ed t o t he superficial venous syst em , i.e., unt il it s arches, t he t reat m ent is m aint ained for at least 3 m ont hs. I n case t he
I n case t he event occurs in varicose veins, diagnost ic assessm ent using DS will be a det erm inant when choosing t he conduct , and t he surgery can be perform ed first , aft er a brief period of
t herapeut ic ant icoagulat ion, in case t here is no concom it ant DVT or PE.
I n case of segm ent im pairm ent in isolat ed and dist al leg veins, ant icoagulat ion m ay not be necessary init ially, focusing on local cares and a new assessm ent 7 days lat er, or if t here is worsening in clinical st at us. I n case t here is proxim al ext ension of t he t hrom bus or m aj or
sym pt om at ology in t he affect ed lim b, UFH or LMWH in t herapeut ic doses should be used, in addit ion t o local cares. I f t here is evolut ion t o DVT and/ or PE and/ or m aint enance or worsening of
A syst em at ic review on t he t reat m ent of lower lim b ST concluded t hat AI NH and LMWH seem t o be t he best t herapeut ic opt ions, significant ly reducing ST ext ension and recurrence when com pared wit h placebo.6 4 However, furt her st udies are needed t o safely est ablish t he best t herapeut ic
schem e.6 4
The act ual benefit of each t herapeut ic m et hod or t heir associat ion rem ains unclear. Fut ure st udies on t he t reat m ent of ST are needed t o est ablish t he best opt ion. Prospect ive, m ult i- cent er and
random ized st udies using a sam ple populat ion t hat is large enough t o obt ain st at ist ical power should collect dat a regarding nat ural hist ory of t his disease, such as frequency of com plicat ions associat ed wit h each t herapeut ic approach ( clinical or surgical) , presence of varicose veins, t hrom bus ext ension in t he superficial venous syst em , t hrom bus propagat ion inside t he DVS, frequency of associat ed concom it ant DVT ( non- cont iguous) , frequency of PE, frequency of associat ed venous insufficiency, recurrence rat e, and screening for associat ed hypercoagulabilit y fact ors.1 0 , 4 2 , 6 1 - 6 3 Based on t he
knowledge of t hese charact erist ics and on evidence, it will be possible t o choose t he best t reat m ent opt ion for each pat ient .
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Correspondence: Marcone Lim a Sobreira Em ail: m lsobreira@gm ail.com
No conflict s of int erest declared concerning t he publicat ion of t his art icle.
