Features

Leg pain and inflammation: why nurses need to think superficial vein thrombosis

Superficial thrombophlebitis is under-recognised, but if left untreated it can lead to DVT

A specialist nurse explains how her nurse-led clinic is improving the care pathway for patients with a frequently-overlooked condition that has potentially very serious outcomes

  • Patients and some clinicians may be unaware of the signs and symptoms of superficial thrombophlebitis, also known as superficial vein thrombosis
  • Find out how to spot signs of thrombus in a superficial vein and advise patients about treatment and self-management
  • How one trusts nurse-led clinic has developed a patient group direction to speed-up access to care and reduce physician time
Picture: iStock

Tell a patient they have superficial thrombophlebitis (STP) and you may well be greeted with a blank look.

This is not surprising because STP

...

A specialist nurse explains how her nurse-led clinic is improving the care pathway for patients with a frequently-overlooked condition that has potentially very serious outcomes

  • Patients – and some clinicians – may be unaware of the signs and symptoms of superficial thrombophlebitis, also known as superficial vein thrombosis
  • Find out how to spot signs of thrombus in a superficial vein and advise patients about treatment and self-management
  • How one trust’s nurse-led clinic has developed a patient group direction to speed-up access to care and reduce physician time
STP is a condition where thrombus and inflammation form in a superficial vein
Picture: iStock

Tell a patient they have superficial thrombophlebitis (STP) and you may well be greeted with a blank look.

This is not surprising because STP – or superficial vein thrombosis (SVT), as it has also recently been termed – is not always well understood, even among healthcare professionals.

Why early recognition and timely diagnosis are so important

STP is a condition where thrombus and inflammation form in a superficial vein.

Recognising the signs and symptoms of this common condition is important for clinical staff practising outside the field of thrombosis, particularly nurses and other professionals in primary care, where patients with STP commonly present.

It is now recognised that STP is more than just a minor condition with little associated risk, and debate continues about its most appropriate management.

If left untreated, thrombus in a superficial vein may extend into the deep veins, resulting in a deep vein thrombosis (DVT), which in turn increases the risk of complications such as a potentially life-threatening pulmonary embolism (PE).

It is thought that 5-10% of patients with STP may develop these complications and 25% may be found to have concurrent DVT or PE.

Where does superficial thrombophlebitis occur and how common is it?

It is seen most often in the veins of the leg, although it can occur in other parts of the body, such as the arm. Commonly, the affected leg veins are the short and long (great) saphenous veins. Up to 80% of patients with STP will have a history of varicose veins.

The veins of the leg

While a small isolated area of STP in the lower leg may be managed safely in primary care, patients with above-knee symptoms or rapidly-progressing below-knee symptoms should be referred promptly to a specialist service for assessment and imaging because of the risk of DVT and its associated risk of PE.

A lack of studies in this area means the prevalence of STP is unclear, but it is likely to be higher than that of DVT, which is estimated at 1-2 per 1,000 in the adult population.

Signs and symptoms of superficial thrombophlebitis

Typically, the patient will present with a red, inflamed vein that may be palpable and cord-like.

The individual is likely to describe a sensation of burning, throbbing and itching.

The surrounding tissue may be red, warm and indurated and is often acutely painful to the touch.

If varicose veins are present, they may be engorged, inflamed and tortuous.

These signs can be confused with those of the bacterial skin infection cellulitis.

In severe cases, the pain can limit the patient’s mobility, interfere with sleep, and generally have a significant effect on their activities of daily living.

Who is most at risk of STP and what are the risk factors?

STP usually occurs when one or a combination of the following conditions are present:

  • Venous stasis (pooling of blood).
  • Hypercoagulability (increased blood clotting).
  • Vessel wall damage.

Risk factors (see box below) are similar to those for DVT. A significant number of patients present with a history of varicose veins, the most common risk factor in STP. This is because varicose veins are usually caused by faulty valves that result in the development of dilated veins, sluggish flow and pooling of blood – all features that make thrombus formation more likely.

Twice as many women as men are affected by STP and people in occupations involving prolonged standing, such as hairdressing, catering and care work, seem particularly vulnerable, especially if they have varicose veins.

Patients will often report a recent period of inactivity or illness but conversely, we regularly see patients who have developed symptoms after a period of unusually intense activity such as running or cycling. Often there will be no obvious precipitating factor.

Risk factors for superficial thrombophlebitis

  • Varicose veins
  • Trauma
  • Recent surgery
  • Prolonged immobility
  • Pregnancy/post-partum period
  • Obesity
  • Cancer
  • Oral contraception or hormone replacement therapy
  • Clotting disorders
  • Autoimmune disorders
  • Intravenous therapy (usually related to arm)
  • History of superficial thrombophlebitis
  • Older age

Source: National Institute for Health and Care Excellence


Benefits of nurse-led fast-track assessment and patient group direction

At Addenbrooke’s Hospital in Cambridge, our team of nurse specialists in the thrombosis treatment team (TTT) provide a fast-track assessment service for patients with suspected deep vein thrombosis 365 days a year.

Our clinic is nurse-led, but we have access to medical staff in the adjacent ambulatory care unit. We see about 1,500 patients a year, most of them referred from primary care. The number of patients presenting with symptoms of STP is rising – our data show an 80% increase in the past five years and we now see around 150 cases a year.

In response to this upward trend, in 2019 our team, led by a consultant haematologist, developed a trust guideline to stratify and standardise treatment.

We also developed a patient group direction (PGD) that enables appropriately trained nurses to manage a sub-group of these patients using anticoagulant drugs, without the need for immediate medical review. This improves the patient’s care experience, as it avoids a potentially long wait in an often crowded waiting room, while also reducing physician time.


How we assess patients in our nurse-led clinic

When a patient attends our clinic for the first time, a nurse will take a clinical history, examine both legs and review the patient’s individual risk factors.

Our priority is to assess whether DVT is likely. We use the two-level DVT Wells score for this. A score of two points makes DVT likely and one point or less, unlikely. A D-dimer blood test may be taken as part of the assessment.

Generally, symptoms of STP will be confined to a superficial vein, whereas DVT often results in more generalised swelling, with pain located over and around the deep veins. If DVT or STP are suspected, we arrange an ultrasound scan the same day.

Superficial thrombophlebitis typically presents as a red, inflamed vein that feels hard and cord-like
Superficial thrombophlebitis typically
presents as a red, inflamed vein that
feels hard and cord-like Picture: SPL

First and foremost, we do this to assess for DVT. If STP is present, the scan enables us to assess the size of the thrombus and its proximity to the deep venous system. It is difficult to accurately determine the extent of the condition by clinical assessment alone; often the thrombus will extend beyond the area of pain and inflammation. The ultrasound scan allows us to confirm diagnosis and guides subsequent treatment.

We have found that patients with STP often have a low or zero Wells score. There is no similar scoring system available for use in diagnosing STP. Similarly, the D-dimer test is often normal in these patients and should not be relied on to exclude STP.

During the assessment, other conditions need to be considered that may require prompt medical review, such as Achilles rupture or acute cellulitis. Less acute conditions, for example mild cellulitis, lymphoedema or venous eczema and ulcers can be referred back to the GP to manage following discharge.

If chest symptoms are present, such as shortness of breath, chest pain, dizziness or syncope, a PE should be considered, and the patient referred for urgent medical review.

Treatment options for STP

Anticoagulant treatment is extremely effective in reducing the risk of further clot extension, recurrence of clot, DVT and PE. A clinical trial in 2010 found that treating patients with a prophylactic dose of Fondaparinux (an injectable synthetic form of heparin) reduced this risk by 85% and presented a very low risk of major bleeding.

In our trust, we use a prophylactic dose of Dalteparin (a low molecular-weight heparin injection) or Rivaroxaban 10mg tablet daily. Our preference is to use oral anticoagulation for patient ease, comfort and convenience. In a more recent trial, these options have been shown to be as effective as Fondaparinux.

Treatment will depend on the location and extent of the thrombophlebitis, as measured on a whole-leg ultrasound scan. Our trust guideline reflects this with its three possible treatment scenarios (see box below).

Patients with STP or DVT require baseline blood tests before starting treatment.

Treatment regimens for patients with superficial thrombophlebitis

Scenario 1

The patient has a small (<5cm) isolated area of STP in the great or small saphenous vein or segments in branch varicosities.

Treatment Non-steroidal anti-inflammatory drugs (NSAIDs) for one week, with or without compression hosiery.

Management By the thrombosis treatment team.

Scenario 2

The patient has a more widespread, extensive STP, >5cm in length but not within 3cm of the junction with the deep veins (the sapheno-femoral/sapheno-popliteal junction).

Treatment Rivaroxaban* 10mg once a day for 42 days or Dalteparin* 5,000 units subcutaneous once daily for 45 days.

Management By the thrombosis treatment team using the patient group direction

Scenario 3

The patient has STP within 3cm of the deep veins (the sapheno-femoral/sapheno-popliteal junction).

Treatment 12-week regimen with therapeutic Rivaroxaban 15mg twice-daily for three weeks then 20mg daily for nine weeks.

Management Treat as DVT, with review by medical staff.

* Off-label use

Source: Cambridge University Hospitals NHS Foundation Trust

Patient information after STP diagnosis

We provide every patient with an information sheet explaining the condition in detail, possible complications and advice about how to manage the symptoms (see box below).

Although many patients find topical treatments effective in reducing pain and inflammation, there is no evidence to suggest they help prevent either progression of the clot into the deep veins or the formation of a new clot.

It is therefore important to ensure patients are made aware of the signs of DVT and PE, and urged to seek immediate medical attention should these occur.

6 self-care strategies to recommend to patients

Patients should be advised to avoid sitting or standing all day
Patients should be advised to avoid
sitting or standing all day Picture: iStock

Support patients to manage their symptoms of superficial thrombophlebitis by offering the following advice:

  • Elevate the limb when resting to help reduce swelling and improve blood flow
  • Avoid sitting or standing for long periods and remain mobile to reduce the risk of developing deep-vein thrombosis
  • Anti-inflammatory painkillers such as ibuprofen may ease the pain (not advised in pregnancy). Paracetamol is an alternative
  • Anti-inflammatory cream or gel or Heparinoid cream may offer some relief
  • A warm compress applied directly over the vein may ease discomfort
  • Compression hosiery may ease discomfort and reduce swelling

Source: Patient

How quickly will STP symptoms improve?

If anticoagulant treatment is required and there are no contraindications, we counsel all patients on the safe use of medication and offer dosing advice, written information and an alert card.

Every patient receives the TTT’s contact details and is advised to contact the team promptly if they have any concerns or worsening of symptoms. Lifestyle factors such as smoking and obesity may also be discussed before discharge.

We telephone every patient 7-10 days after diagnosis to review their symptoms. A repeat scan is not arranged routinely unless there is a significant worsening of leg symptoms.

Where STP is suspected, an ultrasound scan is used to confirm diagnosis and guide subsequent treatment
Where STP is suspected, an ultrasound
scan is used to confirm diagnosis and
guide subsequent treatment Picture: SPL

Patients often expect to see a rapid improvement in their symptoms once treatment has begun, so it is important to advise them it can take some time for symptoms to settle fully and that a palpable vein may be felt for many weeks or months.

Pain and swelling should gradually improve and there is often a distinctive change in skin appearance as the reddened skin changes to a persistent brown pigmentation over the affected vein – this can be difficult to observe in darker skins.

Can use of compression hosiery help?

Graduated compression hosiery may be offered to help alleviate swelling, provide limb support and generally improve comfort for many patients. However, there is no clear evidence that compression hosiery alone can prevent the progression of the clot in STP.

Compression hosiery is contraindicated in patients with arterial disease or peripheral neuropathy; if there is any suspicion of this the patient will be referred back to primary care for further assessment and measurement of ankle brachial pressure index if required.

Assessment for surgical treatment

We offer all patients with significant STP a referral to a vascular surgeon for assessment. Surgical treatments such as ablation or sclerotherapy may be offered. These treatments can help prevent both recurrence of the condition and long-term complications.

Patients with no risk factors and spontaneous onset of STP may undergo further investigations for underlying malignancy.

We maintain a database of all patients whose treatment follows the current trust guideline, recording symptom improvement, clot extension, recurrence, major bleeding, new cancers and whether vascular treatment was offered. Long-term audit will look at whether vascular surgery helps to prevent recurrence.

Early signs are encouraging and we continue to audit our care pathway and PGD.

Think STP – my top tips for non-specialist nurses

  • Superficial thrombophlebitis (STP) usually affects veins in the lower limbs – commonly the long and short saphenous veins
  • Remember STP is often associated with varicose veins
  • Be mindful of the increased risk of deep-vein thrombosis (DVT)/pulmonary embolism (PE), particularly when symptoms are above the knee
  • Clinical assessment alone often underestimates the extent of STP, so a whole-leg ultrasound scan is recommended if you have concerns
  • Antibiotics are not recommended unless there are clinical signs of infection
  • A patient with mild symptoms may be helped by compression hosiery and oral NSAIDs, if tolerated
  • Anti-inflammatory cream or gel may also provide relief in mild cases or if oral NSAIDs are contraindicated
  • The aim of treatment is to relieve symptoms and reduce risk of DVT and PE
Gill O’Brien, clinical nurse specialist, thrombosis, at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust

Further reading


Resources

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to nursing standard.com and the Nursing Standard app
  • Monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs