Varicothrombophlebitis

Thrombosis and inflammation within varicose veins. It is the commonest form of superficial thrombosis (about 60 to 80% of superficial venous thrombosis arises in varicose veins). Varicose veins affect about 20 to 30% of adults in many populations, and the incidence of thrombosis in varicose veins is higher in women, the obese and the elderly.

• Mechanism: incompetent valves in saphenous trunks and tributaries cause slow, turbulent flow and stasis, with endothelial injury and local inflammation. Triggers: prolonged standing or sitting, immobility, trauma, hot weather, long travel, pregnancy and the puerperium, oestrogen therapy, surgery, sclerotherapy and cancer.
• About 25% of patients have concurrent deep vein thrombosis at presentation, and about 5 to 10% develop deep vein thrombosis or pulmonary embolism within 3 months without anticoagulation. The risk is highest when thrombus is 5 cm or longer or lies near the saphenofemoral or saphenopopliteal junction.
• Without treatment of the underlying reflux, recurrence is common (about 10 to 30%), and chronic venous changes (pigmentation, lipodermatosclerosis, ulcer) follow.

• A painful, red, warm, firm and ropey varicose segment, often with a palpable hard cord, tenderness, local swelling and overlying skin induration. Pain increases on walking and standing. Low grade fever may occur. In extensive disease the whole tributary or trunk is tender.
• Purulence and high fever suggest infection, which is uncommon.
• Differential diagnosis: cellulitis (diffuse erythema, no cord), deep vein thrombosis (swelling of the calf or whole leg), ruptured Baker cyst, erythema nodosum, lymphangitis, panniculitis, acute lipodermatosclerosis and localised vasculitis.
• Complications: extension to the deep veins with deep vein thrombosis and pulmonary embolism, recurrence, haemorrhage from a varix (rare), persistent pain, pigmentation, lipodermatosclerosis and venous ulcer.

• Clinical, confirmed by duplex ultrasonography of both legs: thrombus length and its distance from the saphenofemoral and saphenopopliteal junctions, extent of the thrombosed segment, concurrent deep vein thrombosis, and a map of reflux (reflux time greater than 0.5 seconds in superficial veins, greater than 1.0 second in femoral and popliteal veins).
• Blood tests: full blood count with platelets, creatinine, CRP. D-dimer has no role. Thrombophilia and cancer tests only for unprovoked, recurrent, migratory or young onset disease.

• Symptomatic care:
  • Walking, leg elevation when seated, and class 2 compression stockings (20 to 30 mmHg) or bandage for 2 to 4 weeks.
  • Topical diclofenac 1% gel 2 to 4 g four times daily for 7 to 14 days.
  • Oral NSAID for 7 to 14 days: ibuprofen 400 mg three times daily with food, or naproxen 500 mg twice daily, with omeprazole 20 mg daily in patients at gastric risk. Avoid with renal impairment, peptic ulcer, heart failure, anticoagulant use and after 20 weeks of pregnancy.
  • Paracetamol 1 g four times daily.
• Thrombus evacuation for painful, tense segments within the first week (rapid pain relief, evidence is limited): under local anaesthesia with lidocaine 1% (maximum 4.5 mg/kg without adrenaline), make 2 to 3 mm stab incisions over the thrombosed varix and express the clot with a spoon or firm pressure, then apply a compression bandage for 1 to 2 weeks.
• Anticoagulation by extent:
  • Thrombus 5 cm or longer and more than 3 cm from the junction: fondaparinux 2.5 mg SC daily for 45 days (1.5 mg daily when creatinine clearance is 20 to 50 mL/min; contraindicated when less than 20 mL/min), or enoxaparin 40 mg SC daily for 45 days (20 mg daily when creatinine clearance is less than 30 mL/min), or rivaroxaban 10 mg daily for 45 days (avoid when creatinine clearance is less than 15 mL/min).
  • Thrombus less than 5 cm: symptomatic care with duplex ultrasonography at 7 to 10 days; add enoxaparin 40 mg daily for 10 to 14 days with additional risk factors (previous venous thromboembolism, cancer, immobility, recent surgery).
  • Thrombus within 3 cm of the junction or extending into the deep veins: give therapeutic anticoagulation for at least 3 months with rivaroxaban 15 mg twice daily for 21 days then 20 mg daily, or apixaban 10 mg twice daily for 7 days then 5 mg twice daily, or enoxaparin 1 mg/kg SC twice daily overlapped with warfarin to INR 2.0 to 3.0.
• Antibiotics are not needed unless infection is present: flucloxacillin 500 mg to 1 g four times daily (clindamycin 300 to 450 mg three times daily if penicillin allergic) for 7 days.
• Definitive treatment of the varicose veins (reduces recurrence and complications), once inflammation settles (usually 6 to 12 weeks):
  • Endovenous thermal ablation (laser or radiofrequency) or non-thermal closure of the incompetent saphenous trunk, with closure rates of about 90% at 5 years.
  • Foam sclerotherapy with polidocanol 1 to 3% (maximum 10 mL per session) for tributaries and recurrent varices.
  • Ligation and stripping or ambulatory phlebectomy where ablation is unsuitable.
  • Class 2 or 3 compression stockings (20 to 30 or 30 to 40 mmHg) after treatment.
• Special groups:
  • Pregnancy and puerperium: enoxaparin 40 mg SC daily (20 mg under 50 kg, 60 mg for 91 to 130 kg, 80 mg for 131 to 170 kg) for at least 6 weeks; avoid warfarin, direct oral anticoagulants and NSAIDs after 20 weeks; delay definitive treatment until after delivery.
  • Cancer: enoxaparin 40 mg SC daily for at least 45 days, with therapeutic dosing for extension.
  • Elderly and renal impairment: adjust anticoagulant doses by creatinine clearance; avoid NSAIDs.
  • Heparin induced thrombocytopenia: stop heparin; fondaparinux 2.5 mg SC daily is acceptable.
• Red flags: whole leg swelling, chest pain or breathlessness, fever with pus, thrombus extending toward the junction, severe or increasing pain despite treatment, bleeding from a varix.
• Follow up: duplex ultrasonography at 7 to 10 days and at the end of treatment; review at 6 weeks; vascular referral for ablation; yearly review of venous disease and skin.