|Year : 2019 | Volume
| Issue : 4 | Page : 95-97
A review on superficial venous thrombosis of the lower extremities
Yung-Wei Chi1, Sergio Gianesini2, Sheng-Ming Wang3
1 University of California, Davis Vascular Center, Department of Cardiovascular Medicine, Sacramento CA, USA
2 University of Ferrara, Department of Surgery, Ferrara, Italy
3 The First Affiliated Hospital, Sun Yat-Sen University, Division of Vascular Surgery, Guangzhou, China
|Date of Submission||16-Nov-2019|
|Date of Decision||28-Nov-2019|
|Date of Acceptance||29-Nov-2019|
|Date of Web Publication||25-Feb-2020|
Dr. Yung-Wei Chi
University of California, Davis Medical Center, 4860 Y Street, Suite 3400, Sacramento, CA 95817
Source of Support: None, Conflict of Interest: None
Superficial venous thrombosis of the lower extremity is a common medical condition worldwide. Most of its epidemiologic data have come from the Western hemisphere suggesting female predominance and a high risk of venous thromboembolism. Initial diagnosis is still based on clinical suspicion and physical findings, but duplex ultrasound is often required to rule out concomitant deep venous thrombosis. Management options, including surgical and medical means, have been attempted with inconsistent result. In the last decade, clinical trials using anticoagulants such as low molecular weight heparin and new oral anti-Xa anticoagulants have demonstrated beneficial effects. Currently, oral nonsteroidal anti-inflammatories with or without compression are still the predominant initial treatment despite the proven clinical efficacy of oral anticoagulation in lowering thrombotic risk and symptom relief. In this review, most of the studies analyzed are after the year 2010 through PubMed index search and thus making it a contemporary update.
Keywords: Anticoagulation, deep venous thrombosis, pulmonary embolism, superficial venous thrombosis, venous thromboembolism
|How to cite this article:|
Chi YW, Gianesini S, Wang SM. A review on superficial venous thrombosis of the lower extremities. Vasc Invest Ther 2019;2:95-7
| Introduction|| |
Superficial venous thrombosis (SVT) of the extremities is a common medical condition affecting the lower extremity more than the upper extremity. Although both extremities are subjected to Virchow's triad, unique etiologies of SVT to the upper versus the lower extremities are different: upper extremity SVT is usually related to intentional manipulation such as IV placement, indwelling catheter, catheterization, and pacemaker wire. Lower extremity SVT [Figure 1] is commonly related to varicose veins with variable clinical presentation. It is often viewed as a benign condition, but both epidemiologic and natural history follow-up studies suggested a high risk of venous thromboembolism (VTE). In this review, relevant epidemiologic and clinical outcome studies through PubMed index search are analyzed and discussed.
| Epidemiology|| |
Based on epidemiology data, lower extremity SVT occurred more frequently than upper extremity at a rate of 1:1000., Based on this number, the overall prevalence of lower extremity SVT was estimated to affect 3%–8% of the general population with a female predominance. Referencing the STEPH community-based study, this female predominance trend was evident in those <44 years of age and above 65 years age. In the age group between 45 and 64 years, the event rate was higher in men.
One of the major concerns in those suffered from lower extremity SVT was the inherent risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Epidemiologic and cohort analysis such as the OPTIMEV study and the Danish National Registry had indicated an overall prevalence of concomitant DVT in 30% of patients with SVT. In the first 3 months following an isolated lower extremity SVT event, the risk of clinical VTE was estimated to be between 3% and 4% with an average death rate of 1.2%., This suggested a high VTE risk in the first 3 months with a hazard ratio of 71.4. Moreover, the risk of the more serious form of VTE, PE could not be underestimated. It was approximated that about 1/3 of SVT cases were complicated by asymptomatic PE, and life-threatening PE occurred in 2%–13% patients.,, Besides the high VTE event rate in SVT, this risk remained elevated for 5 years after the index event. In affirmation to the Danish National Registry conclusion, the cross-sectional ICARO study of 411 consecutive patients demonstrated a 7.5% VTE event rate within 3 years of the index SVT with an overall VTE rate of 12.7%. These epidemiologic studies indicated that SVT was far from being a benign entity.
| Management|| |
The management of SVT had been controversial. Before the early 2000s, clinical trials of SVT treatment included surgery, anticoagulation, and anti-inflammatories yielded variable results. The meta-analysis from the University of Michigan, albeit its limited scope, had been the most comprehensive analysis of surgical ligation versus anticoagulation in the management of SVT. Seven studies were analyzed, four surgical and three anticoagulation. This meta-analysis indicated a high surgical complication rate of 7%–9% versus a low bleeding rate in the anticoagulation group. It suggested anticoagulation was better in decreasing VTE rate. Overall surgery reduced immediate pain compared to anticoagulation which took longer to exert its full effect. Most recent clinical trials on SVT treatment had been shifted to anticoagulation management. In particular, two randomized controlled trials deserve attention. First was the CALISTO trial. It was a double-blinded randomized control trial that stratified 3000 patients into two arms, fondaparinux 2.5 mg qd versus placebo qd for 45 days, and a total follow-up to day 77. Primary efficacy endpoints included composite death from any cause, symptomatic PE, symptomatic DVT, symptomatic extension of SVT into the saphenofemoral junction, or symptomatic recurrence of SVT on day 47. The main safety outcome was major bleeding rate. The result demonstrated a six-fold decrease in primary event rate in the fondaparinux group compared with placebo and no difference in bleeding rate. In all subgroup analyses those randomized to fondaparinux fared better than the placebo group. The second trial was the open-label SURPRISE study which randomized 500 patients to either fondaparinux 2.5 mg qd or rivaroxaban 10 mg qd. The study was designed as a noninferiority trial with the same primary endpoints as outlined in the CALISTO study. The only other difference was the follow-up, 45 days of treatment and 45 days of follow-up with a total of 90 days. The trial concluded that there was no difference between either the fondaparinux or rivaroxaban in primary event or bleeding rate, P = 0.0025 for noninferiority. While during the 45 days of treatment, both groups had low event rate, in the following 45 days after cessation of treatment, there was an increase in primary endpoints. This reaffirmed the prior notion that these patients were at inherent elevated VTE risk after index event, even after 45 days of anticoagulation. In consideration of the cross-sectional ICARO study, it demonstrated an annual primary event rate of 1.3% in those who were on anticoagulation versus 4.4% in those who were not, again reiterated the beneficial effect of anticoagulation in alleviating thrombotic risk in SVT.
Other management modalities, such as compression therapy, were scarce in recent clinical trials. An Austrian study which randomized patients to either compression stockings or no compression stockings demonstrated no difference in perceived pain according to visual analog scale over 21 days. However, in this trial, all patients received low molecular weight heparin at prophylactic dose, and oral nonsteroidal anti-inflammatories were allowed. The compression stocking group had a faster resolution of thrombus length during the first 7 days of randomization.
In all, there were only two guidelines [Table 1] over the past decade which discussed the management of SVT. The American College of Chest Physician 2012 guideline recommended low molecular weight heparin or fondaparinux 2.5 mg qd for SVT ≥5 cm in length for 45 days without a concluding statement on the use of compression stockings. The American Society of Hematology 2018 guidelines for the management of VTE: VTE in the context of pregnancy endorsed the use of low molecular weight heparin over unfractionated heparin or no anticoagulant in the management of acute SVT in pregnant patients.
| Discussion|| |
SVT had been considered a benign condition by many without significant consequences. However, published data had pointed toward a high prevalence of VTE associated with SVT rendering it no longer an innocent entity. It should also be recognized that in most cases, SVT led to venous insufficiency, not only causing symptoms and incapacity to work but also creating the background for stasis, recurrent thrombosis, and skin changes which may lead to venous ulcers.
An understanding of the epidemiology of SVT is crucial in determining which patients are at increased risk with appropriate management. Compression, anticoagulation, and mobilization are the mainstay of the treatment of acute SVT not only for symptom relief but also to mitigate the risk of VTE. High quality randomized controlled trials have demonstrated beneficial effects of anticoagulation using either lower molecular weight heparin or new oral anti-Xa anticoagulants for at least 45 days. After the relief of symptoms and signs associated with the acute phase, great attention should be taken in the chronic phase, where venous insufficiency can develop and leads to symptoms, work incapacity, and skin changes. This may involve surgical or minimal invasive intervention on the thrombotic and/or recanalized superficial veins. All in all, appropriate management strategy of SVT requires astute attention to persistent thrombotic risk, mitigate symptoms, and recurrence of SVT.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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