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Three Part Question

In [adults with thrombi in their superficial veins of the lower extremity], does [anticoagulation] lead to [improved outcomes and fewer complications]?

Clinical Scenario

A 61-year-old lady presents to the ED with redness and swelling around a varicose vein that extends from the lateral aspect of the left knee to the mid-portion of the lateral aspect of the left leg. She has a 25-year history of asymptomatic lower extremity varicosities which appeared after the birth of her first child. A duplex ultrasound confirms your clinical diagnosis of "superficial thrombophlebitis". You begin treatment with a nonsteroidal anti-inflammatory drug (NSAID), compression stockings and arrange follow-up in 2-3 days. Although she has no risk factors for hypercoagulability or deep venous thrombosis, you wonder if anticoagulants might reduce complications.

Search Strategy

Medline 1966-04/16 using OVID interface, Cochrane Library (2016), and Embase

[(exp superficial phlebitis/ or exp superficial thrombophlebitis/ or exp superficial vein thrombosis/) AND (exp Heparin, low molecular weight / or exp anticoagulants/ or exp coumarin/ or exp fondaparinux/)]. Limit to English language.

Search Outcome

68 studies were identified; one meta-analysis addressed the clinical question. This review, published in 2013, considered 30 randomized controlled trials. There have been no additional RCTs published which relate to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Di Nisio M et al 2013 Italy	6462 participants with superficial thrombophlebitis to leg	Meta-analysis	Fondaparinux vs placebo	DVT and PE RR= 0.15	Only a minority of trials compared treatment with placebo rather than an alternative treatment, none evaluated the same treatment comparisons on the same study outcomes (which precluded meta-analysis), and many of the studies were small and of poor quality. The randomization sequence was adequately generated in only 11 studies. Twelve studies did not attempt to blind the assessment of the outcomes or did not report whether blinding was used or not.
			Fondaparinux vs placebo	Extension of ST RR= 0.08
			Fondaparinux vs placebo	Mortality RR=2.0
			Fondaparinux vs placebo	Any Adverse event RR 0.97
			Prophylactic LMWH vs placebo	Extension and/or recurrence of ST RR=0.44
			Prophylactic LMWH vs placebo	Venous thromboembolism 3-month follow up RR=1.22
			Therapeutic LMWH vs Placebo	Extension and/or recurrence of ST RR=0.46
			Theraoeutic LMWH vs placebo	venous thromboembolism 3-month follow up RR 0.85
			Fondaparinux vs placebo	Recurrence of ST RR 0.21

Comment(s)

Traditionally, superficial thrombophlebitis treatment has varied. Improving local symptoms is important, but the prevention of a venous thromboembolism and reduction in ST progression is important. Multiple treatment options exist, including fondaparinux, low-molecular weight heparin, unfractionated heparin, non-steroidal anti-inflammatory agents and topical treatments.

Clinical Bottom Line

The use of prophylactic fondaparinux for 45 days is a therapeutic option for superficial thrombophlebitis of the leg to help prevent symptomatic ST and reduce ST extension and recurrence.

References

1. Di Nisio M et al Treatment for superficial thrombophlebitis of the leg (Review) Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004982