Date:  April 7, 2013
Title: She’s Got Legs (Deep Vein Thrombosis and Thrombophlebitis)

Case Scenario: A 58-year-old woman arrives to the ED with a painful leg. You do an appropriate history and physical examination. She is Well’s criteria low so you order a d-dimer. The d-dimer comes back elevated so you ask for an ultrasound. This imaging test comes back saying “no evidence of deep vein thrombosis”. You make the diagnosis of superficial thrombophlebitis.

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Question: What should you do to treat this woman’s superficial thrombophlebitis (NSAIDs, coumadin, LMWH, surgery, nothing)?

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Background: Superficial thrombophlebitis is a common problem usually involving the superficial veins of the leg. The two components of this condition are clot (thrombus) and inflammation of the vein (phlebitis). Besides local pain, superficial thrombophlebitis can cause red, itchy skin with hardening of the surrounding tissue. There has been a concern that superficial thrombophlebitis could lead to the more serious deep vein thrombosis.

Reference:  Di Nisio et a. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD004982.

  • Population: RCTs that included participants with a clinical diagnosis of superficial thrombophlebitis of the legs and objective diagnosis of a thrombus in the superficial vein. 26 trials involving 5,521 patients
  • Intervention: Topical treatments, compression stockings/bandages, leg elevation, medical (LMWH, NSAIDs, unfractionated heparin, fondaparinux) and surgery (ligation, vein stripping, crossectomy)
  • Comparison: Compared to another form of treatment, placebo or no intervention.
  • Outcome: Symptoms, extension or recurrence of ST, progression to DVT/PE and quality of life. Secondary outcomes included mortality or adverse effects of treatment.

Results: Fondaparinux given for 45d, compared to placebo, reduced the composite primary end point (death, symptomatic PE/DVT, extension or recurrence of ST) by 85% (RR 0.15; 95% CI 0.08 to 0.26) with a NNT of 20 (95% CI, 15 to 25). Each component of this composite primary end point was reduced except for death. The risk of the composite of DVT or PE was also reduced by 85% (RR 0.15; 95% CI 0.04 to 0.50) with an NNT to prevent one PE or DVT of 88 (95% CI, 54 to 190). There was no increased risk of bleeding compared to placebo.

Fondaparinux: Synthetic factor Xa inhibitor. A potential advantage of fondaparinux is the lower risk for heparin-induced thrombocytopenia (HIT) compared to LMWH or unfractionated heparin . It needs to be used with caution in patients with renal dysfunction because of its renal excretion.There is a black box warning about epidural/spinal hematoma risk for fondaparinux.

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Authors’ Conclusions: “Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs.”

BEEM Comments: This is a typical Cochrane review with good methods addressing a common problem seen in the ED. The quality of most included trials was poor due to inadequately reported randomization and allocation concealment. One very large placebo controlled randomized trial (CALISTO, N=3002) dominated this SR, with over half of all the patients.

This systematic review showed fondaparinux worked. In the other smaller studies, LMWH or NSAIDs compared to placebo, appear to reduce the extension and recurrence of superficial thrombophebitis but had problems with methods and risk of increasing gastric complications. These studies showed no significant difference in the progression to PE or DVT. The evidence for topical treatment or surgery was too limited to draw any conclusions.

BEEM Bottom Line: : Fondaparinux SC OD for 6 weeks should be considered for treating thrombophlebitis of the leg.

Case Resolution: You treat this woman with Fondaparinux to relieve her symptoms and prevent extension to DVT/PE.

KEENER KONTEST: No winner last week:( It is always a challenge picking a question in the Goldie Locks Zone Question (not too easy, not too hard – just right). 

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’ Guide to Emergency Medicine.