UOTW #77

46 yo f presents with LLE pain. On physical exam you note an area of redness on the lateral aspect of the thigh. Ultrasound demonstrates the following image. What is the appropriate management of the patient?

Answer

 

ANSWER:  Anticoagulation

    • This patient presents with a superficial venous thrombosis of >5cm in length
    • Further evaluation of the SVT demonstrates extension into the common femoral vein (A deep vein)
  • A superficial venous thrombosis (SVT) often presents with an area of redness, pain, warmth along the distribution of a superficial vein, often with a palpable cord.
  • SVT is estimated to occur at a rate of 4 per 1000 per year in the US.1
  • SVT’s have traditionally thought to be a benign disease, and treated with NSAIDS and warm compresses.2
  • However, recent literature shows that the rate of concomitant DVT and PE can be as high as 25% and 5%, respectively. 3
  • Current ACCP guidelines recommend treatment with fondaparinux or LMWH if the SVT is >5cm in length.4

REFERENCES

  1. Blumenberg RM, Barton E, Gelfand ML, Skudder P, Brennan J. Occult deep venous thrombosis complicating superficial thrombophlebitis. Journal of vascular surgery. 27(2):338-43. 1998. [pubmed]
  2. Cosmi B. Management of superficial vein thrombosis. Journal of thrombosis and haemostasis : JTH. 13(7):1175-83. 2015. [pubmed]
  3. Frappé P, Buchmuller-Cordier A, Bertoletti L. Annual diagnosis rate of superficial vein thrombosis of the lower limbs: the STEPH community-based study. Journal of thrombosis and haemostasis : JTH. 12(6):831-8. 2014. [pubmed]
  4. Kearon C, Akl EA, Comerota AJ. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141(2 Suppl):e419S-94S. 2012. [pubmed]

  1. The Vessel is not compressible. DVT. Start low molecular heparin, infections parameters and d-dimer. If respiratory symptoms, the further diagnostics.

    1. Thrombus in the femoral vein . Likely DVT unless proven otherwise. To start enoxaparin 1.5mg/kg sc if there are no contraindications for anticoagulation and arrange a diagnostic Doppler to confirm the diagnosis and extent of the clot. If any respiratory symptoms then to consider PE and treat accordinlgy

  2. We see incompressible vessel filled with echogenic material. The vein is great saphenous vein , because is situated in the saphenous compartment between the superficial and deep fascia with so called ” egyptian eye ” configuration. So the diagnosis is superficial vein thrombohplebitis. With normal and not thrombosed deep veins the risk for PE is practically absent so no need to worry about that. Also evaluation of the valve competency in the SFj is advisible to better understand the patophysiology. The management will be supportive with compression stockings , i would give doxycicline also with some dressings, LMWH for about 14 days, and the reconsider about switching to OAT

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