Thrombi most commonly form at the venous cusps of deep veins in the lower extremities, where altered or static blood flow initiates clot formation. Blood clots are primarily composed of red cells, fibrin, and platelets. An immature thrombus may propagate, dissolve, or embolize, depending on various local and systemic factors related to thrombogenesis (especially venous stasis and activation of the coagulation pathway) and the body's defenses responsible for clot lysis (antithrombin III, protein C, plasmin, and other factors). The signs and symptoms of DVT are typically due to a partially or totally occluded vein, leading to venous outflow obstruction and/or the variable inflammatory response to a clot adhering to endothelium. PE may sometimes be the first and only clinical indication of an existing DVT in 10 percent of patients.
A postphlebitic syndrome (PPS) may develop following the resolution of a DVT and is related to valvular incompetence and persistent venous outflow obstruction. The true incidence of PPS is unknown, but studies have revealed a range of 20 to 60 percent depending on the criteria used for diagnosis. 2 Superficial Thrombophlebitis
Thrombosis can occur in any superficial vein, especially in varicosities at the saphenous vein or its tributaries. It is a common, benign, self-limiting process but can cause significant incapacitation. Local pain, redness, and tenderness of a cord along the course of the involved vein are typical findings. Bruising or bleeding may also be noted at the involved site. Doppler ultrasound may be used to confirm the diagnosis if there is any ambiguity or if an alternative diagnosis such as a DVT, cellulitis, or lymphangiitis is possible. Demonstration of flow within the involved vein reliably excludes superficial venous thrombosis.
Mild cases can be treated with warm compresses, analgesia, and elastic supports for the involved extremity with the patient continuing daily activities as tolerated. Severe thrombophlebitis where the patient is functionally debilitated by symptoms should be managed with periods of bed rest, elevation of the extremity, support stockings, and analgesia. Anti-inflammatory medications are commonly used to treat superficial thrombophlebitis. Antibiotics and anticoagulants are of no proven benefit. The incidence of DVT and subsequent PE due to a superficial thrombus is extremely low. Improvement with aggressive therapy can be painfully slow, and symptoms may persist for weeks. Definitive treatment for refractory or recurrent disease is excision of the involved vein. Patients with recurrent or migratory thrombophlebitis should be investigated to exclude a malignancy or other hypercoagulable state.
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