Intern Ultrasound of the Month: Superficial Thrombophlebitis

-Dr. Josiah Smith

Case Presentation

Middle aged male with active tonsillar cancer being treated with chemoradiation presented to the ED for 2 days of progressive pain, redness, and swelling in his left forearm. Symptoms started slightly below his antecubital fossa and gradually spread distally to his wrist.. Had a peripheral IV in his left AC 5 days prior to onset of symptoms though which he received IV chemo. No systemic symptoms. ROS otherwise negative. Of note, he is on long-term warfarin for prior DVTs but currently being held for recent peg tube placement.

He arrived to the ED hemodynamically stable, afebrile, well-appearing. Exam notable for well-demarcated erythema and warmth over ventral aspect of left forearm extending from ~2cm below AC to his wrist. Tender to palpation over the affected area, slightly worse centrally. No open wounds, fluctuance, palpable masses. Neurovascularly intact. No joint involvement.

Point-of-care ultrasound findings

Llnear probe in short axis over the mid forearm revealed a superficial, well-circumscribed, hypoechoic structure with intraluminal echogenicity that was not compressible.

Also viewed in long axis (not shown), it extended horizontally across the entire screen, suggesting a vessel rather than abscess/mass.

thrombophlebitis.gif

Color flow applied and no flow within the structure was noted

thrombophlebitis2.gif

The structure was traced proximally, a few centimeters distal to AC with similar findings.

thrombophlebitis3.gif

Moving proximally in long axis, you can see that this structure converges with another, supporting the notion that this is a vessel.

thrombophlebitis4.gif

Continuing more proximally (in short axis), just above the AC, the vessel lumen became fully anechoic and flow visualized. Though not shown here, it was also fully compressible, thus confirming that this is a vein with thrombosis distally. Pulsatile artery seen on the right of the screen in far field. Deep vein adjacent to it.

thrombophlebitis5.gif


Diagnosis: Superficial Thrombophlebitis

—Ultrasound Findings, Pearls & Pitfalls—

  • Direct visualization of thrombus

  • Lack of compressibility

  • Lack of color flow

  • Don’t confuse with abscess (you don’t want to cut into this!!!)

    • Trace proximally & use color doppler to confirm it’s a vessel

    • “Squish sign” (swirling/movement of contents with compression) suggests abscess

  • Differentiate vein vs artery (look proximal to thrombus)

    • Compressibility? — favors vein but depends on volume status

    • Wall thickness? — thicker wall favors arteries but can be difficult to assess in distal vessels

    • Pulsatility? — favors arteries but also depends on volume status (***use light continuous compression to better assess, 5minsono_artvsvein)

    • Apply color doppler

  • Signs of infection (thrombophlebitis tends to be inflammatory)

    • Cobblestoning —> cellulitis

    • Dirty shadows —> emphysema (suggesting necrotizing infection)

Overview of superficial thrombophlebitis

  • What is it?: pain/ inflammation + thrombus within the superficial venous system

    • Pain & inflammation of vein but no thrombus = phlebitis

    • Part of broader category of superficial venous thrombosis

https://commons.wikimedia.org/wiki/File:Veins_of_the_forearm_and_hand.jpg

https://commons.wikimedia.org/wiki/File:Veins_of_the_forearm_and_hand.jpg

  • Risk Factors: female, older age, vessel cannulation, hypercoagulable states, hyper/hypotonic or irritant infusions (including chemotherapeutics)

  • Signs/symptoms: erythema, warmth, tenderness of affected area. May have palpable cord. May develop systemic sx if suppurative

    ***Mimics cellulitis, milder necrotizing infection, DVT, abscess

  • Diagnosis: primarily clinical, but ultrasound helps assess clot burden/location & evaluate for mimickers

  • Prognosis: usually self-limited but consider severity and comorbidities

    • Consider re-evaluated in 7-10 days to assess for progression

  • Treatment: elevate extremity, warm compresses, NSAIDs

    • Antibiotics? not routinely indicated but consider patient comorbidities, signs of infection, overall clinical status

  • Risk for venous thromboembolism (DVT, PE)?

    • Upper extremities: very low risk but poorly studied Cochrane Review 2015

    • Lower extremities: slightly increased risk, primarily if larger clot (>5cm), non-varicose veins, or hypercoagulable state/high risk Cochrane Review 2018

      • These patients may benefit from low dose anticoagulation x 45 days but evidence is controversial (must weight benefit with bleed risk)

      • Clot within 3cm of saphenofemoral junction in lower extremities should be treated like DVT

Back to the case…

Patient diagnosed with superficial thrombophlebitis based on soft tissue involvement with likely occluded cephalic vein based on location/distribution. He was provided with warm compresses and pain control. Given his immunocompromised status, basic labs obtained and unremarkable. Based on the progression of his symptoms, immunocompromised status, and recommendation by his oncologist, he was admitted for pain control and observation. While inpatient, the primary team ordered a DVT ultrasound study which was negative. His home warfarin, which had been held for recent peg tube placement, was restarted (given his prior DVTs). Patient did well, symptoms started to improve, and he was discharged two days later.

Conclusions/Why Does POCUS Matter?

  • Color Doppler and compression are your friends!

    • Rule out abscess & avoid I&D!

  • POCUS confirms clinical diagnosis & helps guide management

    • Differentiate from abscess, cellulitis, necrotizing infection, etc.

    • May avoid more advanced diagnostic imaging (time, radiation, cost, etc)

    • Avoid unnecessary antibiotics

    • Can expedite time to diagnosis & disposition

Just another example of POCUS for the win! :)


References

Beyer-WestendorfJ. Controversies in venous thromboembolism: to treat or not to treat superficial vein thrombosis. Hematology Am SocHematolEducProgram. 2017;2017(1):223–230.M DN, Im W, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2018; (2). . 

Nisio DM, Aws R. Cochrane Database of Systematic Reviews Treatment for superficial infusion thrombophlebitis of the upper extremity (Review). 2015;(11).

Zehnder, James MD. Catheter-related upper extremity venous thrombosis. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com

http://blog.5minsono.com/artvsvein/

http://5minsono.com/svt/