Current aspects in the management of superficial vein thrombosis

759
Athanasios Giannoukas

Superficial vein thrombosis is not a rare disease, with an incidence of 0.64 in 1,000 annually.1 The POST, OPTIMEV and STEPH studies have shown that superficial vein thrombosis may be associated with a considerable risk of concomitant deep vein thrombosis (24.9–26.3%) or pulmonary embolism (3.9–6.8%).1-4 Additionally, even in the case of isolated superficial vein thrombosis, the risk of a subsequent symptomatic deep thrombosis or pulmonary embolism three to six months later is still high (0.6–3.1% and 0.3–0.9%, respectively).4 These observations underline the importance that superficial vein thrombosis should no longer be considered as a separate entity, but as part of venous thromboembolic disease such as deep vein thrombosis (DVT) and pulmonary embolism.

The most important consideration is whether superficial vein thrombosis develops in the presence of varicose veins or not. In the absence of varicose veins—which is less frequent, consistuting onle 5–10% of all superficial thromboses), the main saphenous trunk is very often involved and the possibility of the presence of malignancy, hypercoagulability and autoimmune disease should be investigated.5–7 In the presence of varicose veins, which is the most frequent scenario, superficial vein thrombosis is commonly confined to greater saphenous vein tributaries and in 5–10% may affect both limbs.2,8,9 In the course of diagnosis, colour flow duplex imaging is recommended for the confirmation of diagnosis and the extent of thrombosis, as well as for the exclusion of concomitant DVT and in follow-up.

In the management of superficial vein thrombosis there is no place for antibiotics unless there is history of placement of indwelling catheters in the affected veins. The role of aspirin and non-steroid anti-inflammatory drugs orally or locally and hirudoid locally is not well-defined and they are mostly used to alleviate pain and local inflammatory signs.

When superficial vein thrombosis coexists with DVT or when the extent of thrombus is close to saphenous junctions (<3cm), treatment with low molecular weight heparins (LMWHs) in therapeutic doses for three months is recommended.10 For superficial vein thrombosis away from the junction (>3cm) and with thrombus extent more than 5cm, 2.5mg of Fondaparinux for 45 days is recommended on the basis of the Calisto study.11 However, the results of this study attracted criticism, as such long-time treatment of all superifical thrombis cases in real-world practice may not be necessary,  as well as issues with cost-effectiveness.12  As it has been demonstrated, treatment with intermediate doses of Tinzaparin for about two weeks was effective in about a third of superficial vein thrombosis patients, especially when the thrombosis was confined to below-the-knee veins and the patients were sufficiently mobilised.13

The use of intermediate doses of LMWHs for at least one month is recommended as compared to prophylactic doses for shorter periods.10,14 In a recent study, it was demonstrated that extended three-month treatment with Tinzaparin in intermediate doses was more effective in terms of venous thromboembolism recurrence as compared to two-month treatment with variable Tinzaparin dose (0% vs. 15.3%, p=0.004).15

Interestingly, in the placebo group of the Calisto study,11 subgroup analysis showed an increased incidence of symptomatic venous thromboembolism complications at day 47 if one of the following characteristics was present at inclusion: age >75 years; BMI ≥30kg/m2; CrCl <50mL/min; history of DVT or pulmonary embolism more than six months previously; history of superficial vein thrombosis more than three months previously; absence of varicose veins at inclusion; superficial vein thrombosis above the knee; superficial vein thrombosis involving the great saphenous vein; distance between the thrombus head and the saphenofemoral junction <10cm.

The Surprise study, a recent non-inferiority study comparing 10mg oral administration of Rivaroxaban once daily versus subcutaneous administration of Fondararinux 2.5mg once daily for 45 days, showed that Rivaroxaban was not inferior in preventing venous thromboembolism complications in high-risk patients. During treatment in both groups venous thromboembolism was very rare but DVT occured slightly more frequently in the Rivaroxaban group (3/211 vs. 1/224). No major bleeding occured and the incidence of minor bleeding until day 45 was the same in both groups (6%), but the clinically relevant non-major bleeding occured more often in the Rivaroxaban group (6/211 vs. 1/224). Additionally, during follow-up a rebound phenomenon was present in both groups resulting in primary efficacy outcome after 90 days in 15 patients (7%) in both groups. Again, DVT was more frequent in the Rivaroxaban group (6/211 vs. 2/224).16

Finally, surgical treatment with elastic stockings was associated with lower venous thromboembolic rate and superficial vein thrombosis progression compared to elastic stockings alone,17 while a review of six studies comparing surgical therapy to anticoagulation showed that surgery was superior in rapid symptom relief, but was associated with higher incidence of venous thromboembolism and complications.18

In summary, venous thromboembolic complications of superficial vein thrombosis are not infrequent and high-risk patients, who may need a prolonged treatment, while in intermediate and low-risk patients a prophylactic dose (2.5mg) of fondaparinux for 45 days or intermediate doses of LMWHs for a month is enough. Based on the existing evidence, superficial vein thrombosis should be considered as part of venous thromboembolic disease, like DVT and pulmonary embolism.

Athanasios Giannoukas is professor and head of the Vascular Surgery Department at University Hospital of Larissa in Volos, Greece.

References

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