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An older man with pain in the leg

One of our very fit, older, patients complained of a pain on the inner aspect of his thigh. ‘Have I pulled a muscle’? He wondered.

When I examined his leg I could feel a line of ropiness on the inner thigh, that meandered around a little. It felt like a piece of rope under the skin. He said that it had progressed up the inner thigh. That didn’t sound like a pulled muscle to me……

On ultrasound scanning I could see that the Saphenous Vein had some solid matter in it. This meant that the vein could not be compressed by the scanner probe. This was thrombus: coagulated blood. Veins can normally be compressed (unlike arteries, which have much stiffer walls). His deeper vein, the femoral vein could be compressed, so he did not have a deep venous thrombosis

What he had was a Superficial Thrombophlebitis (STP). What was the best thing to do?

STP is more common than DVT [1], increasingly common with age [2] and more frequent in females [3]. There are fewer complications from it in older patients [4].

What causes it? It can happen spontaneously [5], but in the Great Saphenous vein, the most common reason is varicose veins [6], which was the case for my patient.

What are the complications? The most worrying is possible pulmonary embolism, if the thrombus is near a junction with the deep venous system [7] [8].

How is it diagnosed? The thrombotic vein is hard and non-compressible. Physical examination tends to underestimate the extent of the thrombus [4] so ultrasound is recommended, mainly to exclude DVT, which can be found in many cases [9]

How is it treated? There is a considerable variation of opinion [10] about how best to manage STP. NSAIDS are said to reduce progression and recurrence of SVT [1]. There is some evidence that anticoagulation treatments are a good idea, particularly for patients with STP further up the leg [1, 3, 11], unless they have kidney function problems.

Bottom line: for a patient with suspected STP in the upper leg , particularly if the thrombus is more than 5cm in length, or near the junction with the femoral vein, they should probably have a specialist ultrasound scan to confirm the diagnosis, and have an opinion about whether they should have some anticoagulation therapy [5, 11].

My patient was adamant that he did NOT want to be put on an anticoagulant and asked me whether there are foods that he could eat that would have anticoagulant properties. It seems that there are some foods that either magnify or diminish the blood-thinning effect of Warfarin, but I can’t find any evidence to support the use of any foods or supplements that have an anticoagulation effect on their own. If you know any research articles that demonstrate how any foods or supplements may be used for anticoagulation , please let me know!

Many thanks to H Nasr for writing the BMJ article [5] which forms the basis of this short summary. Protocols for the NHS DVT service provided in Oxfordshire are here.

To help preserve anonymity, the ultrasound images used in the video above are not of my patient. They are images from Radiopedia, an excellent resource for any clinician interested in diagnostic ultrasound. 

1.     Di Nisio, M., I.M. Wichers, and S. Middeldorp, Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev, 2013(4): p. CD004982.

2.     Rosendaal, F.R., Risk factors for venous thrombosis: prevalence, risk, and interaction. Semin Hematol, 1997. 34(3): p. 171-87.

3.     Decousus, H., et al., Superficial venous thrombosis and venous thromboembolism: a large, prospective epidemiologic study. Ann Intern Med, 2010. 152(4): p. 218-24.

4.     Marković, M.D., et al., [Acute superficial thrombophlebitis–modern diagnosis and therapy]. Srp Arh Celok Lek, 1997. 125(9-10): p. 261-6.

5.     Nasr, H. and J.M. Scriven, Superficial thrombophlebitis (superficial venous thrombosis). BMJ, 2015. 350: p. h2039.

6.     De Maeseneer, M., Treatment of superficial thrombophlebitis of the great saphenous vein. Phlebology, 2008. 23(6): p. 299.

7.     Chengelis, D.L., et al., Progression of superficial venous thrombosis to deep vein thrombosis. J Vasc Surg, 1996. 24(5): p. 745-9.

8.     Bergqvist, D. and H. Jaroszewski, Deep vein thrombosis in patients with superficial thrombophlebitis of the leg. Br Med J (Clin Res Ed), 1986. 292(6521): p. 658-9.

9.     Leon, L., et al., Clinical significance of superficial vein thrombosis. Eur J Vasc Endovasc Surg, 2005. 29(1): p. 10-7.

10.   Dua, A., et al., Variability in the management of superficial venous thrombophlebitis among phlebologists and vascular surgeons. Perspect Vasc Surg Endovasc Ther, 2013. 25(1-2): p. 5-10.

11.   Tait, C., et al., Guidelines on the investigation and management of venous thrombosis at unusual sites. Br J Haematol, 2012. 159(1): p. 28-38.

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