What is Venous Thrombophlebitis?
Thrombophlebitis is the blockage of one of the leg veins. Rarely it involves the arm or the neck veins. These veins maybe superficial, next to the skin (Picture 1) or deep within the muscles when they are called Deep Vein Thrombosis.
How do they superficial thrombophlebitis present?
- There is pain and warmth in the affected area
- Red firm, tender and cord like just below the skin
How does Deep Vein Thrombosis present?
- Leg pain
- Leg swelling
- Leg heaviness
- Skin changes above the ankle. (picture 2)
When do I see a doctor?
- If you have a red swollen tender vein.
- If you have a painful swollen leg with sudden shortness of breath which raises doubts about pulmonary embolism.
Why does it happen?
It is due to clotting of the blood and takes place due to improper circulation. (Picture 3) It may be due to:
- Trauma to the vein
- Inherent blood clotting disorders
- Prolonged immobility
What are the risk factors?
- Prolonged immobility – post-opertively,
- Stroke with paralysis of the legs of arms.
- Resence of pace maker within a central vein which irritates the inner lining causing clot formation.
- During pregnancy or after delivery when there is increased pressure in the leg veins.
- Using birth pills or harmone replacement therpay which thickens the blood and makes it clot.
- Family history of blood clotting disorder or tendency to form clots easily.
- Inactivity for long periods of time like long travel in car or flight.
- Age over 60 years
- Having varicose veins which is the cause of superficial thrombophlebitis.
Could venous thrombophlebitis cause serious problems?
If there is involvement of only the superficial veins then the complications are rare. However if the deep veins are involved the complications may be life threatening or cause serious distress to the patient.
- Pulmonary Embolism (PE) – here a part of the clot breaks and dislodges to the lungs blocking its main blood supply with the result there can be no exchange of oxygen which is vital for the survival of the brain and tissues of all organs. It is a life threatening emergency needing urgent management. (picture 5)
What is post-phlebetic syndrome?
This is a life long problem which follows long standing DVT and causes severe distress to the patient due to the permanent incompetence of the damaged venous valves. It mostly occurs months to years after DVT. (Picture 5)
How does post-phlebetic syndrome present?
It causes disabling pain, swelling and heaviness in the affected leg. There is not much cure of this distressing condition and there is no surgical intervention possible till now.
Is there no cure for post-phlebetic syndrome?
The valves are permanently damaged in the deep veins due to DVT leading to their incompetence which means blood cannot move against gravity when we are standing. This leads to severe swelling responsible for distressing pain, discolouration of the ankles and finally ulcers. Much research is being done all over the world for valve replacement but the results are poor and failure rate high.
What are the complications of post-phlebetic syndrome?
- Varicose veins – which is the distension of the superficial veins of the leg. The results of varicose veins surgery in this setting are very poor. Once the patient has DVT, varicose veins surgery should be avoided.
- Swelling may be permanent.
- Discolouration of the skin – this almost inevitably will occur over a few years and the skin will become hard – lipodermatosclerosis. This condition is a precursor to the development of an ulcer. (Picture 6)
What are the measures I can take to prevent this condition. (Self-care steps)?
As I said this condition cannot be prevented but can be relieved or delayed by:
- Keeping the legs elevated at night by using two pillows under your ankles or raising the foot end of the bed. During the day also try to eliminate the pull of gravity by putting your legs up when sitting. (Picture 7)
- Compression stockings – these should be made to order preferably and worn to mid-thigh but in DVT behind the knee may be worn to the knee. They should not be worn at night when your legs are elevated but right throughout the day from the time you get out of bed in the morning to the time you get into bed at night. It should be only removed only while taking a bath. (Picture 8)
- If pain is severe Iboprofen may be taken but should be avoided in kidney disease.
What tests are done to prove the diagnosis?It is important to differentiate between superficial thrombophlebitis and DVT. This is done by:
- Blood tests – there is an elevation of D-dimer which is a naturally occurring clot dissolving substance. This test is not conclusive but indicates further testing. It rules out DVT and identifies people at high risk of developing thrombophlebitis.
- Colour Doppler study – It is a non-invasive test with very high success rate. It is however operator
- CT Scan – This provides visual images of your lungs to show if clots have dislodged to the lungs (PE)
What is the treatment?
- For thrombophlebitis – self–care steps are recommended – leg elevation. Compression stockings and non-steriodal anti-inflammatory drugs. There is no hospitalization needed and the condition normally improves in 3-4 weeks.
- For DVT the following measures are done:
- Blood thinning drugs – Heparin of Low Molecular Weight Heparin (LMWH) are given. They prevent clot from enlarging. This is followed by oral anticoagulants like warfarin or Acetrome or Xoralto for several months to years. They are stopped only when colour Doppler study shows the vein clear of DVT.
- Clot dissolving medication – this is thrombolysis (Urokinase, streptokinase or altepace. They dissolve the clot and are used for extensive DVT or when there is a high probability of developing clots in the lung – pulmonary embolism (PE).
- Graded Compression Stockings – These prevent swelling and reduce the chances of DVT. These stockings may need to be worn for 2 years or more. (Picture 10)
- IVC Filter – If there is failed medical treatment or the anticoagulation is contraindicated due to other medical conditions then an IVC filter is inserted. This is done under local anesthesia via the vein in the groin and the filter is placed in the main vein (IVC) just below the level of the kidneys. This prevents clots from the legs reaching the lungs. (picture 11)
- Varicose veins surgery– This is recommended to prevent the above complications as the incidence of the above complications rises with varicose veins. Varicose veins surgery is done by pin-hole technique using Radio-Frequency Ablation along with sclerotherapy. Once the superficial veins are ablated the blood returns via the deep venous system.
How can I prevent DVT?
- Sitting for long in flight or car journey causes swelling of the ankles and calves increasing the risk of thrombophlebitis in the leg veins. To prevent this the following measures are taken:
- Take a walk. If in flight walk hourly in the isle and if in car stop and walk around the car.
- If walking is not possible then move your legs regularly by flexing your ankles or pressing down on the floor with your toes.
- If the flight or drive is over 4 hours then:
- Avoid wearing tight clothing
- Drink a lot of non-alcoholic fluid to prevent dehydration.
- Stretch your calves by walking at least once an hour.
- If you are at risk of developing DVT ask your doctor for his advice:
- Compression stockings
- Blood thinning injections before the journey.