Superficial Venous Thrombosis for Primary Care Physicians скачать в хорошем качестве

Superficial Venous Thrombosis for Primary Care Physicians

Dr Kevin Fernando discusses superficial venous thrombosis for primary care physicians. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- Let's start with a patient that we might all see in everyday clinical practice in primary care. Caroline is a 66-year-old librarian due to retire shortly. She presents to us in primary care with a burning sensation and redness over a long-standing varicose vein affecting her left leg. She has no past medical history of note, and she's not taking any regular medications. Specifically, she has no history of deep vein thrombosis (DVT) or pulmonary embolism (PE). On examination, we find a tender, warm, erythematous, and cord-like varicose vein extending down her entire left leg. Caroline is apyrexial and hemodynamically stable, and there are no obvious features of DVT. What do we do next? Do we recommend over-the-counter anti-inflammatories, oral or topical, and compression stockings? Do we prescribe some antibiotics, perhaps some flucloxacillin or doxycycline? Do we prescribe some heparinoid gel? Do we have significant concerns about underlying DVT or PE, and perhaps we should check a D-dimer, refer her for Doppler ultrasound assessment, or even commence anticoagulation? Caroline has superficial vein thrombosis, or SVT, which is now the preferred terminology to superficial thrombophlebitis, which is the term I have used for many years. The reason SVT is preferred is because the underlying predominant pathology is that of thrombus formation in a superficial vein with surrounding inflammation of the vessel wall rather than infection of the vein. SVT commonly affects the saphenous veins and their branches in the lower limbs. SVT is a common presentation in primary care, with an estimated incidence of up to around 10%. Unfortunately, the optimal treatment of SVT has previously been poorly defined. That said, antibiotics have no role in the treatment of SVT, except in clear cases of infection or associated cellulitis. SVT is a clinical diagnosis, and symptoms and signs include pain, warmth, redness, and swelling. Often a palpable cord is present, suggesting the presence of thrombus, as is the case with Caroline. Interestingly, migratory thrombophlebitis, or thrombophlebitis migrans, characterized by recurrent SVT at different sites, can be associated with underlying malignancy, particularly pancreatic adenocarcinoma. This is called Trousseau syndrome. Additionally, SVT in the subcutaneous fat of the breast and anterior chest wall, usually in women, can be associated with underlying breast cancer. This is called Mondor disease. Risk factors for SVT are similar to those for DVT and PE and include malignancy, immobilization, obesity, estrogen use or pregnancy, a personal or family history of venous thromboembolism, and inherited thrombophilia, such as factor V Leiden. A key message for us all in primary care is that SVT is a risk factor for concomitant and future venous thromboembolism and warrants more attention than it has perhaps previously received. At diagnosis, around 20%, or 1 in 5, of patients with SVT are found to have associated venous thromboembolism, DVT. Up to 4% of patients with SVT will have an associated PE. Thrombus in SVT can extend into the deep venous system, particularly if the SVT involves veins near the saphenopopliteal junction behind the knee or saphenofemoral junction in the groin. Therefore, Doppler ultrasound is recommended in most cases to confirm the presence of SVT, exclude concurrent DVT, and measure the length of the thrombus and proximity to the saphenofemoral or saphenopopliteal junctions. However, individuals with below-knee SVT are at low risk for thrombus propagation, and if they have no clinical evidence of DVT, they can be managed in primary care with anti-inflammatory therapy, topical or oral, and graduated compression hosiery. However, anticoagulation is recommended for individuals with a high risk for thrombus progression into the deep venous system and possible embolization. According to recently published European Society for Vascular Surgery guidelines on antithrombotic therapy for vascular disease, prophylactic doses of anticoagulation with fondaparinux or rivaroxaban for 45 days are recommended for all individuals with SVT of length greater or equal to 5 cm and over 3 cm from the saphenofemoral or saphenopopliteal junctions. Transcript in its entirety can be found by clicking here: https://www.medscape.com/viewarticle/...