How to identify thrombosis of the great saphenous vein of the legs. Superficial thrombophlebitis of the lower extremities - symptoms and treatment of thrombosis of the great and small saphenous veins Thrombosis of the great saphenous vein of the thigh

For citation: Kiyashko V.A. Thrombophlebitis of superficial veins: diagnosis and treatment // RMJ. 2003. No. 24. S. 1344

D This type of pathology is a very common disease of the venous system, which is faced by a doctor of any specialty.

Currently, in medical practice, terms such as phlebothrombosis and varicothrombophlebitis are also often used. All of them are legal to use, but the following points should be considered. Phlebothrombosis is considered as an acute obstruction of a vein as a result of hypercoagulation, which is the leading mechanism. But at the same time, after 5-10 days, the resulting thrombus causes reactive inflammation of the tissues surrounding the vein with the development of phlebitis, that is, phlebothrombosis is transformed into thrombophlebitis .

The term "varicothrombophlebitis" clearly indicates, in fact, the initial cause of thrombosis that occurs against the background of varicose veins already present in the patient.

The pathology of the venous system listed above in the vast majority of clinical cases occurs in the large system and much less frequently in the system of the small saphenous vein.

Thrombophlebitis of the veins in the upper extremities is extremely rare, and the main provoking factors for their occurrence are multiple punctures for the administration of drugs or a long stay of the catheter in a superficial vein.

Particular attention should be paid to patients with spontaneously occurring blood clots in the upper and lower extremities, not associated with iatrogenic exposure. In such cases, the phenomena of thrombophlebitis can be suspected as a manifestation of a paraneoplastic reaction due to the presence of an oncological pathology in the patient, requiring an in-depth multifaceted examination.

Thrombus formation in the system of superficial veins is provoked by the same factors that cause thrombosis of the deep venous system of the lower extremities. These include: age over 40 years, the presence of varicose veins, cancer, severe disorders of the cardiovascular system (cardiac decompensation, occlusion of the main arteries), physical inactivity after major operations, hemiparesis, hemiplegia, obesity, dehydration, banal infections and sepsis, pregnancy and childbirth, taking oral contraceptives, trauma to the limbs and surgical interventions in the area of ​​passage of the venous trunks.

Thrombophlebitis can develop in any part of the superficial venous system , with the most frequent localization on the lower leg in the upper or middle third, as well as the lower third of the thigh. The overwhelming number of cases of thrombophlebitis (up to 95-97%) was noted in the basin of the great saphenous vein (Kabirov A.V. et al., Kletskin A.E. et al., 2003).

Further development of thrombophlebitis can actually go in two ways:

1. Relatively favorable course of the disease , against the background of the ongoing treatment, the process stabilizes, thrombus formation stops, inflammation subsides, and the process of thrombus organization begins, followed by recanalization of the corresponding section of the venous system. But this cannot be considered a cure, because. there is always damage to the initially altered valvular apparatus, which further aggravates the clinical picture of chronic venous insufficiency.

Clinical cases are also possible when a fibrous thrombus densely obliterates a vein and its recanalization becomes impossible.

2. The most unfavorable and dangerous option in terms of the development of complications of a local nature - ascending thrombosis along the great saphenous vein to the oval fossa or the transition of the thrombotic process through the communicating veins to the deep venous system of the lower leg and thigh.

The main danger of the course of the disease according to the second option is the threat of developing such a complication as pulmonary embolism (PE), the source of which can be a floating thrombus from the system of a small or large saphenous vein, as well as secondary deep vein thrombosis of the lower extremities.

It is rather difficult to judge the frequency of thrombophlebitis among the population, but if we take as a basis the position that among the patients hospitalized in the surgical departments with this pathology, more than 50% had varicose veins, then taking into account the millions of patients with this pathology in the country, this figure looks very impressive and the problem is of great medical and social importance.

The age of patients ranges from 17 to 86 years and even older, and the average age is 40-46 years, that is, the working population.

Given the fact that with thrombophlebitis of the superficial veins, the general condition of the patient and well-being, as a rule, do not suffer and remain quite satisfactory, this creates the illusion of relative well-being and the possibility of various self-treatment methods for the patient and his relatives.

As a result, such behavior of the patient leads to late accessibility for qualified medical care, and often the surgeon is faced with already complicated forms of this “simple” pathology, when there is a high ascending thrombophlebitis or deep vein thrombosis of the limb.

Clinical picture

The clinical picture of the disease is quite typical in the form of local pain in the projection of the saphenous veins at the level of the lower leg and thigh with the involvement of the tissues surrounding the vein in the process, up to the development of a sharp hyperemia of this zone, the presence of seals not only in the vein, but also in the subcutaneous tissue. The longer the zone of thrombosis, the more pronounced the pain in the limb, which forces the patient to limit its movement. Hyperthermic reactions in the form of chills and an increase in temperature up to 38-39 ° C are possible.

Quite often, even a banal acute respiratory disease becomes a provocative moment for the occurrence of thrombophlebitis, especially in patients with varicose veins of the lower extremities.

Inspection is always carried out from two sides - from the foot to the inguinal zone. Attention is drawn to the presence or absence of pathology of the venous system, the nature of the discoloration of the skin, local hyperemia and hyperthermia, swelling of the limb. Severe hyperemia is typical for the first days of the disease, it gradually decreases by the end of the first week.

With the localization of thrombophlebitis in the small saphenous vein, local manifestations are less pronounced than with damage to the trunk of the great saphenous vein, which is due to the peculiarities of the anatomy. The superficial sheet of the own fascia of the lower leg, covering the vein, prevents the transition of the inflammatory process to the surrounding tissues. The most important point is to find out the timing of the appearance of the first symptoms of the disease, the speed of their increase, and whether the patient has attempted to medicate the process.

So, according to A.S. Kotelnikova et al. (2003), the growth of a thrombus in the system of the great saphenous vein goes up to 15 cm per day. It is important to remember that in almost a third of patients with ascending thrombosis of the great saphenous vein, its true upper limit is located 15-20 cm above the level determined by clinical signs (V.S. Savelyev, 2001), that is, this fact should consider each surgeon when consulting a patient with thrombophlebitis of a vein at the level of the thigh, so that there is no unreasonable delay in the operation aimed at preventing PE.

It should also be considered inappropriate to locally administer anesthetics and anti-inflammatory drugs to the area of ​​a thrombosed vein on the thigh, since, by stopping pain, this does not prevent the growth of a thrombus in the proximal direction. Clinically, this situation becomes difficult to control, and duplex scanning can really only be used in very large medical institutions.

Differential Diagnosis should be carried out with erysipelas, lymphangitis, dermatitis of various etiologies, erythema nodosum.

Instrumental and laboratory diagnostics

For a very long time, the diagnosis of thrombophlebitis of superficial veins was made by a doctor on the basis of only the clinical symptoms of the disease, since there were actually no non-invasive methods for characterizing venous blood flow. The introduction of ultrasound diagnostic methods into practice has opened a new stage in the study of this common pathology. But the clinician must know that among the ultrasound methods for diagnosing venous thrombosis, duplex scanning plays a decisive role, since only with its help it is possible to determine the clear boundary of thrombosis, the degree of thrombus organization, the patency of deep veins, the state of the communicants and the valvular apparatus of the venous system. Unfortunately, the high cost of this equipment still sharply limits its practical use in outpatient and inpatient settings.

This study is indicated primarily for patients with suspected embologenic thrombosis, that is, when there is a transition of a thrombus from the superficial venous system to the deep one through the sapheno-femoral or sapheno-popliteal fistula.

The study can be carried out in several projections, which significantly increases its diagnostic value.

Phlebographic study

The indication to it is sharply narrowed. The need for its implementation arises only in the case of a blood clot spreading from the great saphenous vein to the common femoral and iliac vein. Moreover, this study is performed only in cases where the results of duplex scanning are doubtful and their interpretation is difficult.

Laboratory diagnostic methods

In a routine clinical blood test, attention is drawn to the level of leukocytosis and the level of ESR.

It is desirable to study the C-reactive protein, coagulogram, thrombelastogram, the level of the prothrombin index and other indicators characterizing the state of the coagulation system. But the scope of these studies is sometimes limited by the capabilities of the laboratory service of a medical institution.

Treatment

One of the important points that determine the outcome of the disease and even the fate of the patient is the choice of tactics for the optimal treatment option for the patient.

With the localization of thrombophlebitis at the level of the lower leg, the patient can be treated on an outpatient basis, being under the constant supervision of a surgeon. Under these conditions, it is necessary to explain to the patient and his relatives that if signs of thrombosis spread to the level of the thigh appear, the patient may need to be hospitalized in a surgical hospital. Delay in hospitalization is fraught with the development of complications, up to the occurrence of PE.

In cases where thrombophlebitis at the level of the lower leg, treated for 10-14 days, does not regress, there should also be a question of hospitalization and more intensive therapy for the disease.

One of the main issues in the treatment of patients with thrombophlebitis of superficial veins is the discussion the patient's need for strict bed rest .

Currently, it is a recognized fact that strict bed rest is indicated only for patients who already had clinical signs of PE or have clear clinical data and instrumental findings indicating the embologenic nature of thrombosis.

The patient's motor activity should be limited only to severe physical activity (running, lifting weights, performing any work that requires significant muscle tension in the limbs and abdominals).

General principles for the treatment of thrombophlebitis of superficial veins

These principles are indeed common for both conservative and surgical treatment of this pathology. The main goals of treatment these patients are:

• To act as quickly as possible on the focus of thrombosis and inflammation to prevent its further spread.
• Try to prevent the transition of the thrombotic process to the deep venous system, which significantly increases the risk of developing PE.
• Treatment should be a reliable method of preventing recurrent thrombosis of the venous system.
• The method of treatment should not be strictly fixed, since it is determined primarily by the nature of the ongoing changes in the limbs in one direction or another. That is, the transition or addition of one treatment method to another is quite logical.

Undoubtedly, conservative treatment shown to the vast majority of patients with "low" superficial thrombophlebitis of the saphenous veins.

Once again, it should be emphasized that reasonable motor activity of the patient improves the function of the muscle pump, which is the main determining factor in ensuring venous outflow in the system of the inferior vena cava.

The use of external compression (elastic bandage, stockings, tights) in the acute phase of inflammation can cause some discomfort, so this issue should be addressed strictly individually.

Quite controversial is the question of the use of antibiotics in this category of patients. The doctor should be aware of the possible complications of this therapy (allergic reactions, intolerance, provocation of blood hypercoagulability). Also, the question of the advisability of using anticoagulants (especially direct action) in this contingent of patients is far from unambiguously resolved.

The doctor must remember that the use of heparin after 3-5 days can cause thrombocytopenia in the patient, and a decrease in the number of platelets by more than 30% requires discontinuation of heparin therapy. That is, there are difficulties in monitoring hemostasis, especially on an outpatient basis. Therefore, it is more appropriate to use low molecular weight heparins (dalteparin, nadroparin, enoxaparin), since they rarely cause the development of thrombocytopenia and do not require such careful monitoring of the coagulation system. Positive is the fact that these drugs can be administered to the patient 1 time per day. 10 injections are enough for a course of treatment, and then the patient is transferred to indirect anticoagulants.

In recent years, ointment forms of heparin (lyoton-gel, Gepatrombin) have appeared for the treatment of these patients. Their main advantage is rather high doses of heparin, which are delivered directly to the focus of thrombosis and inflammation.

Of particular note is the targeted effect on the area of ​​thrombophlebitic changes of the drug Hepatrombin ("Hemofarm" - Yugoslavia), produced in the form of an ointment and gel.

Unlike lyoton, it contains 2 times less heparin, but additional components - allantoin and dexpanthenol, which are part of the Hepatrombin ointment and gel, as well as pine essential oils, which are part of the gel, have a pronounced anti-inflammatory effect, reduce the effects of skin itching and local pain in the area of ​​thrombophlebitis. That is, they contribute to the relief of the main symptoms of thrombophlebitis. The drug Hepatrombin has a strong antithrombotic effect.

It is applied topically by applying a layer of ointment to the affected areas 1-3 times a day. In the presence of an ulcerative surface, the ointment is applied in the form of a ring up to 4 cm wide around the perimeter of the ulcer. The good tolerability of the drug and the versatility of its impact on the pathological focus puts this medicine at the forefront in the treatment of patients with thrombophlebitis both on an outpatient basis and in hospital treatment. Hepatrombin can be used in a complex of conservative treatment or as a remedy aimed at stopping inflammation of the venous nodes after the Troyanov-Trendelenburg operation, as a method of preparing for the second stage of the operation.

The complex of conservative treatment of patients should include non-steroidal anti-inflammatory drugs also have analgesic properties. But the clinician must remember to exercise extreme caution when prescribing these drugs to patients with diseases of the gastrointestinal tract (gastritis, peptic ulcer) and kidneys.

Well-established in the treatment of this pathology is already well known to doctors and patients phlebotonics (rutoside, troxerutin, diosmin, ginkgo biloba and others) and disaggregants (acetylsalicylic acid, pentoxifylline). In severe cases with extensive phlebitis, intravenous transfusions of 400-800 ml of rheopolyglucin intravenously are indicated for 3 to 7 days, taking into account the patient's cardiac status due to the risk of hypervolemia and the threat of pulmonary edema.

Systemic enzyme therapy in practice has limited application due to the high cost of the drug and a very long course of treatment (from 3 to 6 months).

Surgery

The main indication for surgical treatment of thrombophlebitis, as previously indicated, is the growth of a thrombus along the great saphenous vein above the middle third of the thigh or the presence of a thrombus in the lumen of the common femoral or external iliac vein, which is confirmed by phlebography or duplex scanning. Fortunately, the latter complication is not so common, only in 5% of patients with ascending thrombophlebitis (I.I. Zatevakhin et al., 2003). Although individual reports indicate a significant frequency of this complication, reaching even 17% in this contingent of patients (N.G. Khorev et al., 2003).

Anesthesia methods - different options are possible: local, conduction, epidural anesthesia, intravenous, intubation anesthesia.

The position of the patient on the operating table is of some importance - the foot end of the table must be lowered.

The generally accepted operation for ascending thrombophlebitis of the great saphenous vein is Troyanov-Trendelenburg operation .

The surgical approach used by most surgeons is quite typical - an oblique incision below the inguinal fold according to Chervyakov or the inguinal fold itself. But at the same time, it is important to take into account the main clinical point: if there are instrumental data or clinical signs of a thrombus moving into the lumen of the common femoral vein, then it is more advisable to use a vertical incision that provides control over the thrombosed great saphenous vein and the trunk of the common femoral vein, when sometimes it is required to clamp it on time of thrombectomy.

Some technical features of the operation:

1. Mandatory isolation, intersection and ligation of the trunk of the great saphenous vein in the area of ​​its mouth.

2. When opening the lumen of the great saphenous vein and detecting a thrombus in it that goes beyond the level of the ostial valve, the patient must hold his breath at the height of inhalation during surgery under local anesthesia (or this is done by an anesthesiologist with other types of anesthesia).

3. If the thrombus "is not born on its own", then a balloon catheter is carefully inserted through the sapheno-femoral fistula at the height of inspiration and thrombectomy is performed. Retrograde blood flow from the iliac vein and antegrade from the superficial femoral vein are checked.

4. The stump of the great saphenous vein must be sutured and tied up; it must be short, since a too long stump is an “incubator” for the occurrence of thrombosis, which creates a threat of pulmonary embolism.

In order to discuss options for this routine operation, it should be noted that some surgeons suggest performing thrombectomy from the great saphenous vein in the Troyanov-Trendelenburg operation, and then injecting a sclerosant into it. The feasibility of such manipulation is questionable.

The second stage of the operation - the removal of thrombosed varicose veins and trunks is performed according to individual indications within a period of 5-6 days to 2-3 months as local inflammation is relieved, in order to avoid suppuration of wounds in the postoperative period, especially with trophic skin disorders.

When performing the second stage of the operation, the surgeon must necessarily ligate the perforating veins after preliminary thrombectomy, which improves the healing process.

All conglomerates of varicose veins are to be removed in order to avoid the development of gross trophic disorders in the future.

Surgical treatment of this group of patients is carried out by a very wide range of general surgeons and angiosurgeons. The seeming simplicity of treatment sometimes leads to tactical and technical errors. Therefore, this topic is almost constantly present at scientific conferences.

is a pathological condition characterized by the spread of the thrombotic process from the superficial veins of the lower extremities in the proximal direction. The transition to a deep venous bed is accompanied by intense pain, edema, cyanosis, expansion of the subcutaneous vessels on the side of the lesion, creating a real threat of pulmonary embolism. Pathology is confirmed by the results of ultrasound and phlebography of the venous system, a test for the level of D-dimer in the blood. Treatment involves a combination of conservative (medication, elastic compression) and surgical methods.

ICD-10

I80 Phlebitis and thrombophlebitis

General information

Ascending thrombophlebitis is the most common acute pathology requiring emergency surgical care. During life, it develops in 20–40% of people, being observed in 56–160 people per 100,000 population per year. According to clinical and ultrasound data, the transition of thrombotic occlusion from superficial to deep veins is observed in 6.8–40% of cases. This poses a real threat to the patient, contributing to the development of pulmonary thromboembolism. The disease occurs in all age groups, but usually occurs in people over 60 years of age. Women are affected 2-4 times more often than men.

Causes

The development of ascending thrombophlebitis is subject to the general patterns of thrombus formation in the venous system. The phenomena of stasis with retrograde and turbulent blood flow, coagulation disorders and endothelial damage become the basis for its formation. Trigger factors include:

• Varicose disease. Being the most significant cause of the ascending process, it is observed in 68-95% of patients. Thrombophlebitis occurs as an acute complication of varicose veins in the system of large or small saphenous veins, indicating the ineffectiveness of the treatment of the underlying disease.
• Injuries and operations. Pathology develops under the influence of injuries (fractures, bruises, soft tissue ruptures) and operations. More often complicates surgical interventions on the organs of the abdominal and thoracic cavities, the hip joint. The role of vascular catheterization, endovenous thermoablation (laser, radiofrequency) was noted.
• chronic pathology. The spread of thrombophlebitis in an upward direction is promoted by diseases accompanied by the phenomenon of hypercoagulation. In many patients of the phlebological profile, autoimmune pathology, malignant neoplasms, and thrombophilia are detected (48% of cases).
• Pregnancy and postpartum period. In most women, thrombosis and thrombophlebitis develop in the II and III trimesters of pregnancy, which is facilitated by hormonal changes and a decrease in blood fibrinolytic activity. A significant progression factor is childbirth, which is associated with intrapelvic tension, release of tissue thromboplastin into the blood after separation of the placenta.

The probability of pathology increases with prolonged immobilization - immobilization, strict bed rest, paralysis. Significant risk factors are obesity, taking hormonal drugs (oral contraceptives, substitution therapy), the presence of thrombosis and ascending thrombophlebitis in history.

Pathogenesis

With valve failure, tortuous and dilated veins deposit a large amount of blood, local hemodynamics slows down and becomes turbulent. Congestive processes initiate hypoxia and endothelial damage with the release of pro-inflammatory mediators, leukocyte wall infiltration. Exposure of subendothelial structures, in particular collagen, activates platelets, enhances their adhesion and aggregation. In the zone of microtrauma, the content of tissue plasminogen activator decreases, which is accompanied by inhibition of fibrinolysis.

Venous stasis plays an important role in thrombosis. Congestion weakens protective mechanisms (blood dilution of activated coagulation factors, their washing out and mixing with inhibitors), contributing to the accumulation of thrombotic material. Progressive obstruction leads to further deterioration of hemodynamic parameters. Extended phlebitis and periphlebitis, as well as widespread venous reflux, contribute to the transition of inflammation and thrombosis to the proximal areas.

Many factors influence the rate of development of the pathology: the state of the venous wall, the severity of varicose veins, the age of the patient, concomitant conditions, but above all, the localization of the primary thrombotic focus. With valvular defects, the thrombus more easily penetrates through the saphenofemoral fistula into the femoral vein, where the clot quickly becomes floating. Less often, the transition to a deep channel is carried out through the sapheno-popliteal zone or incompetent perforators.

Classification

The systematization of ascending thrombophlebitis is carried out based on the localization and prevalence of the pathology. Classification, which is most often used in scientific and practical phlebology, contains several types of thrombotic lesions:

• I type. Thrombophlebitis of distal areas (trunk or tributaries). It is still a localized process with no upward propagation.
• II type. The upper border of the thrombus reaches the proximal areas, but without damage to the sapheno-femoral or sapheno-popliteal fistulas.
• III type. There is a transition of thrombotic inflammation to deep venous segments.
• IV type. There is no damage to the ostium, but the process spreads through incompetent perforating veins of the leg and thigh.
• V type. Any variant associated with isolated deep vessel thrombosis of the same or opposite limb.

The presented classification allows predicting the course of the disease and forming the correct treatment tactics. Other authors distinguish 4 forms of thrombophlebitis - local (damage to one or more large tributaries), widespread (transition of the process to the trunks of the superficial veins of the lower leg or thigh), subtotal (thrombosis in the small saphenous vein reaches the popliteal fossa, and in the large - its upper third), total (thrombotic process covers fistulas).

Symptoms of ascending thrombophlebitis

External signs in the superficial bed include erythema and skin tension over the affected areas. The limb swells, the thrombosed vessel is palpated as a dense painful cord surrounded by a zone of local hyperthermia. Acute thrombosis is characterized by pain in the calf muscles, which increases with physical exertion. From the first days of illness, usually in the evening, there is a fever.

A reliable sign of acute phlebothrombosis of the lower leg is soreness of the calf muscles when they are compressed with fingers or a sphygmomanometer cuff. With the defeat of the femoral vein, the symptoms become more pronounced. Occlusion of the saphenofemoral anastomosis is accompanied by a sharp swelling of almost the entire limb. It increases in volume, acquires a cyanotic color, the severity of which increases along the periphery. In the distal part of the thigh and lower leg, an expanded surface network is observed. Venous hypertension arising from thrombosis of the mouth of the great saphenous vein is transmitted to the anastomoses of the opposite side.

Proximal spread of thrombosis, increasing obstruction of collaterals, hemodynamic decompensation make the clinical symptoms as pronounced as possible. The pain syndrome intensifies, moving to the femoral and inguinal zones. The entire limb swells - from the foot to the pupart fold, covering the scrotum, buttocks, the anterior wall of the abdomen on the affected side.

The course of ascending thrombophlebitis is difficult to predict. The spread rate sometimes reaches 35 cm per day, but even in these cases, the development is asymptomatic, which greatly complicates clinical diagnosis. With incomplete obstruction, the latent course is associated with the preservation of an adequate outflow of blood. In such a situation, thrombi become floating and fragmented, which creates a risk of embolization.

Complications

The danger of ascending thrombophlebitis is due to the spread of the process to the deep venous system, which is associated with a significant risk of pulmonary embolism. Explicit symptoms of PE are detected in 5.6-28% of individuals, but many episodes remain unrecognized due to the subclinical course. Mortality with such a formidable complication can reach 10%. Even against the background of adequate therapeutic correction, there is a risk of recurrent thrombotic obstruction, which increases in conditions of reflux from deep veins and chronic hypercoagulation (18–42% of cases). In the long term, the development of post-thrombotic syndrome with symptoms of chronic venous insufficiency is observed.

Diagnostics

The specificity of ascending thrombophlebitis is such that even with a thorough physical examination, it is not possible to accurately determine the upper limit of thrombosis. In a third of patients, the prevalence of occlusion is 15–20 cm higher than expected according to clinical data, which requires the use of more informative diagnostic methods:

• Ultrasound of the venous system. Allows you to determine the location, the presence of flotation, to clarify the border of the thrombus, to identify its spread to the veins of the deep system. Thanks to these criteria, it is possible to predict the further course of the pathology and the risk of PE. With segmental ultrasound angioscanning, the patency of the main vessels, the solvency of the valves, the magnitude and duration of retrograde blood flow are determined.
• X-ray contrast phlebography. It is indicated during the transition of thrombophlebitis to deep vessels above the level of the inguinal fold. According to the results of the study, not only the presence or absence of obstruction is determined, but also its localization, nature and severity, and the ways of collateral blood flow. Venography from a diagnostic procedure, if necessary, can immediately go into a treatment one (for implantation of a cava filter, catheter thrombectomy).
• Blood test forD-dimer. Determination of fibrin degradation products, especially D-dimer, is recommended in the early stages of thrombosis to establish deep segment occlusion. The test has high sensitivity, but low specificity - an increase in the indicator is likely in many concomitant conditions (tumors, inflammatory diseases, pregnancy, etc.).
• tomographic techniques. The spread of thrombotic masses to the ileofemoral segment and the high risk of PE necessitate contrast-enhanced CT of the pelvis and lungs, which makes it possible to accurately visualize the vessels and determine the age of thrombi. Compared to ultrasound, MRI has a higher information content in relation to the study of the veins of the lower leg and pelvis.

Ascending thrombophlebitis has to be differentiated from cellulitis, erythema nodosum, arterial thrombosis. Sometimes it becomes necessary to exclude lymphangitis, panniculitis, periostitis. A phlebologist surgeon manages to establish an accurate diagnosis on the basis of clinical examination data, supported by the results of instrumental and laboratory methods.

Treatment of ascending thrombophlebitis

Patients with an acute process are urgently hospitalized in a specialized hospital (vascular department). To prevent damage to deep segments and pulmonary embolism, such cases require active therapeutic tactics and an integrated approach. Treatment is based on the use of several methods:

• Medicines. Systemic pharmacotherapy is given one of the main places in therapeutic correction. The appointment of anticoagulants (low molecular weight heparins, fondaparinux), non-steroidal anti-inflammatory drugs, venotonics (hydroxyethyl rutosides, diosmin, hesperidin) is pathogenetically justified and necessary. Gels and ointments with heparin, NSAIDs have a local effect.
• Compression therapy. In the acute stage, elastic bandages of medium extensibility are used to improve venous outflow. With a decrease in swelling and the severity of inflammation (after 7–10 days), it is recommended to wear medical knitwear (tights, stockings) of the 2nd compression class.
• Surgical correction. The operation is recognized as the most effective way to prevent complications. If the thrombosis does not reach the ostial valve, then the saphenofemoral junction is ligated. The defeat of the femoral segment requires an emergency operation - thrombectomy and crossectomy (according to the Troyanov-Trendelenburg method) with further therapy with anticoagulants.

In the acute and postoperative periods, it is recommended to maintain physical activity, avoiding prolonged bed rest. Among the physiotherapeutic methods, local hypothermia is used, after the elimination of active inflammation - UHF, UV irradiation, solux. Some studies show the effectiveness of varicothrombophlebitis sclerotherapy in combination with crossectomy and phlebectomy.

Forecast and prevention

The localization of the pathological process and the presence of complications are the main factors affecting the prognosis. The defeat of the deep venous system and the development of PE make it unfavorable. Existing methods of therapeutic correction can significantly reduce the risk of fatal complications in ascending thrombophlebitis, but in some cases the disease recurs, leading to prolonged or permanent disability.

Primary prevention involves normalization of weight, maintenance of physical activity, timely treatment of associated pathology. Medications (anticoagulants, antiplatelet agents, venotonics), elastic compression help prevent relapses.

Thrombosis of the great saphenous vein is the most common complication of varicose or post-thrombophlebitic disease. At the first symptoms of thrombosis, the patient should immediately consult a doctor, to get a referral for emergency surgery.

How to identify thrombosis of the great saphenous vein of the legs

If we talk about the clinical picture, thrombosis occurs against the background of inflammation of the surrounding tissues. A dense infiltrate can be palpated along the course of the vein, the subcutaneous tissue is infiltrated, and the patient experiences sharp pain when walking. But with the help of palpation, a phlebologist cannot make an accurate diagnosis, so angiographic research methods are used.

If thrombosis of the great saphenous vein is localized above the middle third of the thigh, this can be considered an embolism. An additional study is being carried out to exclude the possibility of a thrombus passing beyond the saphenofemoral fistula.

Thrombosis treatment

Saphenous vein thrombosis can only be treated under the direct supervision of an experienced physician. The patient is recommended bed rest, elastic bandaging to fix a blood clot, heparin-containing gels or ointments, phlebotonics, anticoagulants.
If ascending thrombophlebitis is diagnosed, the patient is shown. Most often, a crossectomy is performed, when the veins are tied off, preventing the upward migration of a blood clot.

Thrombophlebitis of the saphenous veins of the lower extremities or superficial thrombophlebitis is a disease in which blood clots appear in the lumen of the saphenous veins. Since the veins are located close to the skin, this phenomenon is accompanied by inflammation - redness of the skin, pain, local swelling.

In fact, thrombophlebitis of the saphenous vein is a "double" disease. Because, firstly, the venous walls themselves become inflamed. And secondly, a blood clot is formed in the vein - a thrombus.

Superficial thrombophlebitis in the vast majority of cases manifests itself as an acute disease. More often, varicose-transformed tributaries of the large (and / or small) saphenous vein, as well as perforating veins, are thrombosed.

Important! If untreated, thrombosis extends to the great (small) saphenous vein itself, and further to the deep veins.

Causes of thrombophlebitis of superficial veins

The cause of any thrombosis is a combination of three factors:

• change in the configuration of the vein (for example, varicose transformation) and, as a result, "swirls" of blood in the lumen of the vessel;
• "thickening" of the blood - a tendency (hereditary or acquired) to thrombosis;
• damage to the vein wall (injection, trauma, etc.).

The main and most common cause of superficial thrombophlebitis is varicose veins. Also, the most common risk factors are:

• genetic predisposition;
• pregnancy and childbirth;
• obesity, hypodynamia;
• endocrine and oncological diseases.

Superficial thrombophlebitis: symptoms and manifestations

In the initial stages, superficial thrombophlebitis of the lower extremities may not be very noticeable in the manifestations. Slight reddening of the skin, burning, insignificant swelling - many patients simply do not pay attention to all this. But the clinical picture changes very quickly, and signs of thrombophlebitis of superficial veins become noticeable and very uncomfortable:

• the appearance of "nodules" and seals in the vein;
• edema;
• sharp pain;
• local increase in temperature;
• discoloration of the skin in the area of ​​​​the inflamed vein.

Treatment of superficial thrombophlebitis

For the treatment of thrombophlebitis of superficial veins, different methods and their combinations are used.

More often it can be conservative treatment:

• compression therapy - wearing compression stockings, special elastic bandaging;
• taking non-steroidal anti-inflammatory and analgesic drugs;
• locally, in the area of ​​inflammation - cold;
• according to indications - taking drugs that "thinn" the blood.

Emergency surgical treatment of acute thrombophlebitis of the saphenous veins is prescribed , as a rule, in cases where thrombosis does not affect the tributaries, but directly the large or small saphenous veins. So, with ascending thrombophlebitis of a large or small saphenous vein, the trunk of the main saphenous vein is thrombosed directly. With the spread of thrombosis of the great saphenous vein to the thigh, thrombophlebitis is considered ascending. For the small saphenous vein, this is the middle and upper third of the lower leg.

In this case (if technically possible), either endovenous laser obliteration or crossectomy is used - ligation of the large (small) saphenous vein along with its tributaries.

If ascending thrombophlebitis has already led to the penetration of a blood clot into deep veins, this is fraught with the occurrence of pulmonary embolism - separation of a blood clot and blockage of the pulmonary artery. This situation occurs when thrombosis spreads from the saphenous veins into the deep (“muscular”) veins.

In this situation (if technically possible), a thrombus is removed from the deep veins and a crossectomy is performed - ligation of the saphenous vein at the mouth.

In the medical field, the term "ascending thrombophlebitis" is commonly understood as inflammation of the walls of a vein and the appearance of a blood clot, as a result of which the lumen of the vein is blocked and blood flow is disturbed. The most common cause of this disease is a complicated form of varicose veins.

The main risks of the manifestation of the disease are considered to be overweight, significant regular physical activity on the lower extremities, old age, pregnancy and childbirth, leg injuries, the postoperative period, and taking hormonal drugs.

Ascending thrombophlebitis is diagnosed in situations where thrombophlebitis from the part of the great saphenous vein located on the lower leg moves up to the inguinal folds.

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During the period of the disease, when the inflammation goes to the deep veins, there is the greatest risk of separation and movement of the thrombus. And this, in turn, can cause a life-threatening complication - pulmonary embolism.

acute form

A fairly common form of complication of varicose veins is acute ascending thrombophlebitis.

This stage of the disease carries a significant risk to the life of the patient, as it allows the possibility of an immediate transition of inflammatory processes to the deep veins in the legs and separation of a blood clot.

A floating thrombus in the veins can soon lead to blockage of the arteries.

Symptoms

Often, the symptoms of ascending thrombophlebitis are pronounced. For this reason, diagnosing this disease is not a difficult task.

The clinical picture is determined by the localization of the inflammatory process, its duration, as well as the scale of distribution. In addition, special attention is paid to the damage to muscle tissues adjacent to the focus of the disease.

Given all these symptoms, doctors establish the form of the disease - from minor inflammatory processes to pronounced ones. The most risky is the manifestation of the disease of the great saphenous veins.

With ascending thrombophlebitis of the saphenous vein, edema of the lower extremities does not occur, and the disease manifests itself as follows:

• on palpation of the inflamed areas, a seal is felt, and the patient experiences pain;
• the temperature of the skin rises;
• subcutaneous tissue is compacted, and the skin has redness;
• while walking, the pain intensifies, there is a constant heaviness in the legs;
• The patient complains of general malaise and weakness.

However, in the case of further spread of the inflammatory process through the blood vessels, large veins are affected, namely: the large subcutaneous, common femoral, and saphenofemoral anastomosis.

In such a situation, the symptoms will be quite pronounced. There are swelling of the lower extremities from the feet to the lower back, accompanied by heaviness and pain.

The attending physician conducts a visual examination of the patient and studies the medical history in detail. In modern medicine, ultrasound is considered the most accurate study of blood vessels.

This type of diagnosis allows:

• assess the condition of the veins;
• determine the presence of blood clots;
• to study the patency of both superficial and deep veins.

In addition, an additional study of ascending thrombophlebitis can be performed using radiopaque phlebography.

After establishing the diagnosis - ascending thrombophlebitis, a complex treatment of the disease is prescribed. The patient is recommended an active mode. Prolonged immobility of limbs should be avoided.

In the process of treatment, a regular intake is prescribed, preventing the formation of blood clots and restoring the tone of blood vessels, as well as anti-inflammatory drugs. With severe symptoms, they are prescribed.

Conservative therapy

In the early stages of the development of the disease, doctors recommend making elastic compression on the legs so that the clot cannot move into large blood vessels.

For this, a bandage from a bandage of medium extensibility is used. The leg is wrapped for a period of 10 days completely from the foot to the groin. After reducing inflammation, the bandage is replaced with compression stockings.

In order to reduce pain in the initial days of the disease, you can resort to an ice compress. Ice is applied several times during the day for 15-25 minutes.

In addition, a number of medications can be prescribed to prevent the formation of blood clots and restore blood vessels:

All medications, elastic bandages and compression hosiery are selected individually by the attending physician - phlebologist

Surgical intervention

Treatment with conservative methods is appropriate only in cases where there is no risk of inflammatory processes moving to deep veins and only when the disease is localized in the lower leg area.

In the event of a possible threat of the transition of inflammation to a deep vein, an operation is performed as soon as possible with ascending thrombophlebitis using surgical intervention.

The most effective method of surgical treatment is crossectomy. The essence of this operation is to ligate and cut the great saphenous veins and their main tributaries in the part where they connect with the deep vein of the thigh.

To perform this operation, a small incision is made in the inguinal fold. Upon completion, a suture is applied. After healing, the scar is almost invisible.

Very often, after removing inflammation, doctors resort to phlebectomy - surgery to remove varicose veins.

Prevention

Ascending thrombophlebitis is considered a dangerous disease of the circulatory system. It takes a lot of time and effort to treat this disease. Therefore, people prone to this disease should remember about preventive measures to prevent the development of this disease.

You need to lead a mobile lifestyle, do gymnastics regularly. To avoid stagnation of blood in the vessels of the lower extremities, you should rest with raised legs (for this you can use a small pillow). In the case of long trips or flights, it is recommended to drink plenty of fluids, change body position more often, and move limbs.

We should not forget about proper nutrition: eat more fresh vegetables and fruits, limit the consumption of animal fats as much as possible.

To prevent the recurrence of the disease, it is necessary to constantly use medical compression stockings, take vitamins and anticoagulants, limit yourself from heavy physical exertion, refuse to visit the bath and sauna, as well as taking hot baths.