Download Great Saphenous Vein Superficial Thrombophlebitis

Great Saphenous Vein Superficial
Thrombophlebitis
Caitlin Gardiner
PATIENT PRESENTATION
A 53 year old women presented to a general radiology practice with localised left leg pain and swelling for 4 days.
Opened ended questions confirm the patient is mobile, has had no recent surgery, has not had any extended
immobile periods recently but does have high cholesterol and blood pressure.
Clinical assessment of the left leg shows the distal thigh, knee and proximal calf to be significantly more swollen than
the right and is extremely painful and hot to touch.
EXAMINATION
The examination was performed on a General Electrics Logiq E9 with a high-frequency linear probe in accordance
with ASAR guidelines and adhering to the ALARA principle. Verbal informed consent was obtained, explaining the
objective of the scan and allowing the patient to ask any questions. Given the patients leg tenderness, it is explained
to her compression of the veins is important which may cause discomfort for her.
The patient understood the requirement to scan from the groin down to the ankle and was offered the privacy to
change into a robe. The patient was positioned supine on an adjustable-height bed and a blanket was used to ensure
the patient felt as modest as possible throughout.
With the left leg slightly externally rotated, the probe is positioned in transverse at the groin crease and the
Common Femoral Artery (CFA) and the Common Femoral Vein (CFV) are located at the sapheno-femoral junction.
The CFV is compressed ensuring complete collapse of the anterior to posterior wall. This is repeated distally along
the vein, as well as the superficial femoral Vein, and representative images are obtained.
The patient is asked to sit on the side of the bed facing the ultrasound machine and the bed is raised to aid
ergonomic scanning. The probe is placed in a transverse plane at the knee crease in the popliteal fossa.
Compressibility of the popliteal vein is assessed. The calf veins are assessed with the probe again in transverse with
the toe on the medial edge of the tibia, ensuring visualisation of the paired posterior tibial and peroneal veins. Their
patency is confirmed in with both compressibility and colour Doppler. See the sample of images below.
Assessment of the Great Saphenous Vein is undertaken. The region, corresponding to the area of most clinical pain
and swelling, demonstrates poor Colour Doppler filling abilities and lack of compression at the knee and proximal
calf. A poorly defined hyperechoic lesion within the area is noted. Compression proximal and distal to the defect are
confirmed. Oedematous tissue creates sub-optimal imaging quality.
RESULTS
The radiologist confirmed that the deep venous system was patent, the CFV, femoral vein, popliteal vein and calf
veins were easily compressible. No intraluminal thrombus was noted and normal augmented flow was noted
throughout. An intraluminal thrombus was demonstrated in the greater saphenous vein at the knee and proximal
calf, consistent with a superficial thrombophlebitis. Significant subcutaneous oedema was noted.
The patient present the next day for an abdominal US, which was on the same referral. The radiologist report
concluded fatty changes to the liver and pancreases but otherwise, no abnormality was detected.
FOLLOW UP
The patient returned to the same radiology practice 7 weeks later for a follow-up ultrasound. Again, no DVT was
demonstrated but a small 43mm remnant area of the thrombophlebitis involving the mid-thigh of the great
saphenous vein was noted. There was no evidence of thrombophlebitis in the lower leg.
The patient informed that her General Practitioner prescribed thrombolytic medication to dissolve the clot in
conjunction with NSAIDS for the acute pain. She was also prescribed long-term anticoagulants to reduce her risk of
developing clots in the future.
DISCUSSION
Superficial thrombophlebitis is an inflammatory-thrombotic disorder in which a thrombus develops in a superficial
vein. Superficial thrombophlebitis is clinical similar to a deep vein thrombosis, though carries far less risk of adverse
outcome. As such, prompt diagnosis is imperative to ensure the appropriate care can be undertaken efficiently
(Goldman and Shafer, 2011).
Though typically a result of medical or surgical intervention or long immobile periods, superficial thrombophlebitis
can occur spontaneously. Additional risk factors include pregnancy, oestrogen therapy, varicose veins, obesity,
cigarette smoking, and intravenous drug abuse, AIDS, trauma, malignancy, various congenital blood condition or
changes of medications. The aetiology is usually attributed to intimal damage from trauma, infection or
inflammation, statis or turbulent flow or changes in blood constituents (Gaffo, 2013). On reflection, the patient did
smell of cigarette smoke and is an appropriate age group for perhaps taking hormone replacement therapies. Whilst
such factor increase the likelihood of a thrombophlebitis, it is noted they are also risk factors for a deep vein
thrombosis. As a result, they are of minimal significance for a sonographer as they do not differentiate between one
another.
Clinical symptoms are typically redness and tenderness tracking along the vein with swelling and sometimes bleeding
(Goldman and Shafer, 2011). Though the patient did not have any bleeding, her clinical symptoms are consistent
with those expected.
Prognosis of superficial thrombophlebitis is usually positive, rarely associated with pulmonary embolism. Can must
be taken to ensure the process does not extend into a deep vein as the risk of embolism is much higher.
Interestingly, patient with superficial thrombophlebitis are only at a slight increased risk of developing DVTs in the
future but proactive measures are usually obtained (Wichers et al, 2005).
The disease process lasts around one month though typically take longer if associated with varicose veins. Without
excision, a persistent firm nodule in subcutaneous tissue may remain. Recanalization of thrombosis may result in a
valveless change and result in chronic venous pressure in the legs, pain, oedema, hyperpigmentation and ulceration
(Di Nisio et al, 2013).
Over the imaging interval of 7-8 weeks, the thrombophlebitis had largely reduced in size and the patient had only
mild clinical symptoms remaining. It is noted that the thrombophlebitis may have migrated slightly to the mid-thigh
when it was original in the knee and proximal calf. Whilst this is likely a remnant (as diagnosed by the radiologist),
migratory superficial thrombophlebitis is a strong indicator for thrombophilia, malignancy and rheumatologic
disease (Lee and Moll, 2014).
REFERENCES
Di Nisio M, Wicher IM, Meddeldorp S, 2013. Treatment for Superficial Thrombophlebitis of the Leg. Cochrane
Database Syt Rev.
Gaffo AL, 2013. Thrombosis in Vasculitis. Best Pract Res Clin Rheumatol; 27(1): 57-67.
Goldman L, Shafer Al, 2011. Goldman’s Cecil Medicine 24th Ed. Philadelphia. Saunders Elsevier.
Lee C, Moll S, 2014. Migratory Superficial Thrombophlebitis in a Cannabis Smoker. Am Heart Assoc; 130: 214-215.
Wichers IM, Di Nisio M, Buller Hr et al, 2005. Treatment of Superficial Vein Thrombosis to Prevent Depp Vein
Thrombosis and Pulmonary Embolism: A Systematic Review. J Vasc Surg; 37(4):834-8.
Quere I, Leizorovicz A, Galanaud JP et al, 2012. Superficial Venous Thrombosis and Compression Ultrasound
Imaging.J Vasc Surg.