Subscribe to RSS
DOI: 10.1055/a-1238-6645
Oberflächliche Venenthrombose der Beinvenen – Eine systematische Übersicht – Teil 2: Therapie
Superficial vein thrombosis of the leg veins – A systematic Review – Part 2: Treatment![](https://www.thieme-connect.de/media/10.1055-s-00034913/202201/lookinside/thumbnails/phlebo-12386645_10-1055-a-1238-6645-1.jpg)
Zusammenfassung
Einleitung Die oberflächliche Venenthrombose (OVT) der Beinvenen ist mit einer Inzidenz von 0,5–1/1000 Einwohner/Jahr ein häufiges und mit einer Frequenz assoziierter thromboembolischer Ereignisse in bis zu 25 % der Fälle ein ernst zu nehmendes Krankheitsbild. In der vorliegenden Übersichtsarbeit sollen alle relevanten Aspekte der OVT basierend auf der aktuellen wissenschaftlichen Literatur behandelt werden.
Methoden Die systematische Übersicht umfasst das Wissen über die OVT basierend auf dem gesamten, systemisch recherchierten Erkenntnismaterial in den Datenbanken PubMed und Google Scholar. Eine Literaturrecherche in PubMed von Publikationen (1968–2018) mit den Suchbegriffen „Superficial vein thrombosis; thrombophlebitis“ ergab 102 aussagekräftige Arbeiten, die nach Vorlage der Originalarbeit ausgewertet wurden. Teil 2 der Arbeit behandelt Aspekte zur Therapie.
Ergebnisse Die Bewertungskriterien der Therapie der OVT sind in den einzelnen Leitlinien und Übersichtsarbeiten z. T. unterschiedlich. Andererseits ist in den letzten Jahren eine zunehmende Stringenz in den Therapieempfehlungen festzustellen, die vom Ausprägungsgrad der OVT abhängig sind. Zu deren Prinzipien gehören die Mobilisation des Patienten und das Tragen eines medizinischen Kompressionsstrumpfes der Kompressionsklasse II. Die medikamentöse Therapie umfasst den Einsatz von Fondaparinux oder niedermolekularen Heparinen. Fondaparinux ist derzeit das einzig zugelassene Medikament für diese Indikation ab einer Thrombusausdehnung von mindestens 5 cm. Rivaroxaban in einer Tagesdosis von 10 mg war gegenüber Fondaparinux in einer randomisierten Studie nicht unterlegen; dies führte jedoch nicht zu einer Zulassung für die Indikation der OVT. Eine therapeutische Antikoagulation hingegen wird empfohlen, sobald sich das proximale Thrombusende 3 cm oder näher zum Übergang in das tiefe Venensystem befindet. Nichtsteroidale Antirheumatika reduzieren das Risiko einer OVT-Extension oder eines Rezidivs und wirken schmerzlindernd. Die Therapie mit Externa bietet nur lokale symptomlindernde Effekte. Eine operative Therapie der OVT kann in bestimmten Situationen erwogen werden, um Varizen, Schmerzen und das Risiko einer Thrombusaszension in einem Behandlungsschritt zu beseitigen.
Schlussfolgerung Aufgrund der Häufigkeit und des Risikos potenziell lebensbedrohender Komplikationen sollte der OVT der Beinvenen eine größere Beachtung zukommen, insbesondere mit Blick auf eine auf den individuellen Befund ausgerichtete Stadien-adaptierte Therapie.
Abstract
Introduction Superficial vein thrombosis (SVT) of the leg veins arises with an incidence of 0,5–1 per 1000 persons per year and is complicated by associated thromboembolic events in 1 out of 4 cases. Thereby SVT is a frequent and serious venous disease. This review covers all relevant aspects of SVT based on the current scientific literature.
Methods This review article comprises the entire knowledge about SVT and is based on a systematic PubMed and Google Scholar search. Selective literature analysis based on a systematic PubMed search of publications between 1968 and 2018 with search terms „superficial vein thrombosis; thrombophlebitis” yielded in 102 relevant publications which were evaluated for this review. Part 2 of this work compiles aspects of treatment.
Results Current guidelines and reviews propose different criteria and recommendations for SVT treatment, whereupon an increasing stringency in the therapy recommendations in recent years can be observed. The correct choice of treatment depends on the individual extent of SVT. Principles of the treatment are patient’s mobilization and the wearing of compression stockings. A treatment with fondaparinux or low-molecular-weight heparin (LMWH) should be considered keeping in mind that Fondaparinux is exclusively approved for SVT treatment in patients with a thrombus length of at least 5 cm. Rivaroxaban with a daily dose of 10 mg was not inferior to Fondaparinux in a single randomized trial, but this did not lead to an approval for SVT. However, a therapeutic full-dose anticoagulation is recommended as soon as the thrombus reached a distance of 3 cm or less to the deep vein system. Non-steroidal anti-inflammatory drugs reduce the risk of an extension of SVT or its recurrence and they reduce pain. A surgical treatment of SVT can be weighed in particular situations to remove varicose veins and eliminate pain and the risk of thrombus ascension within a single step.
Conclusion Because of its high frequency and the risk of potentially life-threatening complications SVT of the leg veins should be more focused, especially in terms of a specific treatment based upon the individual extent of the disease.
Publication History
Article published online:
25 May 2021
© 2021. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
Literatur
- 1 Partsch H, Rabe E, Stemmer R. Superficial thrombosis. Compression therapy of the extremities. Vol. Chapter 10.1.4.2. Paris: Phlebologiques Francaises; 2000: 300-304
- 2 Kalodiki E, Stvrtinova V, Allegra GM. et al. Superficial vein thrombosis: a consensus statement. Int. Angiol 2012; 31: 203-216
- 3 Di Nisio M, Wichers JM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev 2018; 2: CD004982
- 4 Boehler K, Kittler H, Stolkovich S. et al. Therapeutic effect of compression stockings versus no compression on isolated superficial vein thrombosis of the legs: a randomized clinical trial. Eur J Vasc Endovasc Surg 2014; 48: 465-471
- 5 Belcaro G, Cesarone MR, Dugall M. et al. Topical formulation of heparin is effective in reducing the symptoms of superficial venous thrombosis: a monocenter, observer-blind, placebo-controlled randomized study. Panminerva Medica 2011; 53 (03) 3-11
- 6 De Sanctis MT, Cesarone MR, Incandela L. et al. Treatment of superficial vein thrombosis with standardized application of Essaven gel – a placebo-controlled, randomized study. Angiology 2001; 52 (Suppl. 03) 57-62
- 7 Gorski G, Szopinski P, Michalak J. et al. Liposomal heparin spray: a new formula in adjunctive treatment of superficial venous thrombosis. Angiology 2005; 56: 9-17
- 8 Holzgreve A, Kleine W, Stegmann W. Local treatment of superficial thrombophlebitis with nonsteroidal antiinflammatory agents. Zeitschrift Allgemeinmedizin 1989; 65: 663-667
- 9 Incandela L, De Sanctis MT, Cesarone MR. et al. Treatment of superficial vein thrombosis: clinical evaluation of essaven gel – a placebo-controlled, 8-week, randomized study. Angiology 2001; 52 (Suppl. 03) 69-72
- 10 Katzenschlager R, Ugurluoglu A, Minar E. Liposomal heparin-spraygel in comparison with subcutaneous low molecular weight heparin in patients with superficial venous thrombosis. A randomized, controlled, open multicentre study. Journal Kardiologie 2003; 10: 375-378
- 11 Nocker W, Diebschlag W, Lehmacher W. Lokaltherapie bei oberflächlicher Thrombophlebitis. Wirksamkeit eines Diclofenac-Natrium-Gels im Vergleich zu Placebo- und Heparin-Gel. Zeitschrift Allgemeinmedizin 1991; 67: 2214-2222
- 12 Pinto G, Galati D, Bompiani GD. et al. Topical 5‘-methylthioadenosine in the treatment of symptomatic chronic venous insufficiency, haemorrhoids and superficial phlebitis. A double-blind placebo-controlled trial. Drug Investigation 1992; 4: 205-214
- 13 Winter WR, Rauhut K, Arnold S. et al. Lokale Therapie der Thrombophlebitis superficialis – Ein individueller Vergleich von Voltaren-Emulgel versus eines Heparin-haltigen Gels. Zeitschrift Rheumatologie 1986; 45: 180-181
- 14 Samuelson B, Go AS, Sung SH. et al. Initial management and outcomes after superficial thrombophlebitis: The CVRN VTE study. J Hosp Med 2016; 11: 432-434
- 15 Ferrari E, Pratesi C, Scaricabarozzi I. et al. A clinical study of efficacy and tolerability of nimesulide compared with diclofenac sodium in the treatment of acute superficial thrombophlebitis. Minerva Cardioangiologica 1992; 40: 455-460
- 16 Nusser CJ, Schare W, Bernard I. Therapie superfizieller Thrombophlebitiden mit nichtsteroidalen Antiphlogistika. Therapiewoche 1991; 41: 541-544
- 17 Rathbun SW, Aston CE, Whitsett TL. A randomized trial of dalteparin compared with ibuprofen for the treatment of superficial thrombophlebitis. J Thromb Haemost 2012; 10: 833-839
- 18 Decousus H. The Superficial Thrombophlebitis Treated by Enoxaparin (STENOX) Study Group. A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis. Arch Intern Med 2003; 163: 1657-1663
- 19 Titon JP, Auger D, Grange P. et al. Therapeutic managment of superficial venous thrombosis with calcium nadroparin. Dosage testing and comparison with an non-steroidal anti-inflammatory agent. Ann Cardiol Angeiol 1994; 43: 160-166
- 20 Marshall W, Kleine MW. Wirksamkeit und Verträglichkeit einer oralen Enzymtherapie bei der schmerzhaften akuten Thrombophlebitis superficialis. Phlebologie 2001; 30: 36-43
- 21 Belcaro G, Errichi BM, Laurora G. et al. Treatment of acute superficial thrombosis and follow-up by computerized thermography. Vasa 1989; 18: 227-234
- 22 Belcaro G. Evolution of superficial vein thrombosis treated with defibrotide: comparison with low dose subcutaneous heparin. Int J Tissue Reactions 1990; 12: 319-324
- 23 Belcaro G, Nicolaides AN, Errichi BM. et al. Superficial thrombophlebitis of the legs: a randomized, controlled, follow-up study. Angiology 1999; 50: 523-529
- 24 Cosmi B, Filippini M, Tonti D. et al. A randomized double-blind study of low-molecular-weight heparin (parnaparin) for superficial vein thrombosis: STEFLUX (Superficial ThromboEmbolism and Fluxum). J Thromb Haemost 2012; 10: 1026-1035
- 25 Lozano FS, Almazan A. Low-molecular-weight heparin versus saphenofemoral disconnection for the treatment of above-knee greater saphenous thrombophlebitis: a prospective study. Vasc Endovasc Surg 2003; 37: 415-420
- 26 Marchiori A, Verlato F, Sabbion P. High versus low doses of unfractionated heparin for the treatment of superficial thrombophlebitis of the leg. A prospective, controlled, randomized study. Haematologica 2002; 87: 523-527
- 27 Spirkoska A, Jezovnik MK, Poredos P. Time course and the recanalization rate of superficial vein thrombosis treated with low-molecular-weight heparin. Angiology 2015; 66: 381-386
- 28 Uncu H. A comparison of low-molecular-weight-heparin and combined therapy of low-molecular-weight heparin with an anti-inflammatory agent in the treatment of superficial vein thrombosis. Phlebology 2009; 24: 56-60
- 29 Prandoni P, Tormene D, Pesavento R. Vesalio Investigators Group. High vs. low doses of low-molecular-weight heparin for the treatment of superficial vein thrombosis of the legs: a double-blind, randomized trial. J Thromb Haemost 2005; 3: 1152-1157
- 30 Junqueira DR, Zorzela LM, Perini E. Unfractionated heparin versus low molecular weight heparins for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev 2017; 4: CD007557
- 31 Decousus H, Prandoni P, Mismetti P. et al. for the CALISTO Study Group. Fondaparinux for the treatment of superficial-Vein thrombosis in the legs. N Engl J Med 2010; 363: 1222-1232
- 32 Bauersachs RM. The Calisto-study. Phlebologie 2011; 40: 79-83
- 33 Werth S, Bauersachs R, Gerlach H. et al. Superficial vein thrombosis treated for 45 days with rivaroxaban versus fondaparinux: rationale and design of the SURPRISE trial. J Thromb Thrombolysis 2016; 42: 197-204
- 34 Beyer-Westendorf J, Schellong SM, Gerlach H. et al. Prevention of thromboembolic complications in patients with superficial-vein thrombosis given rivaroxaban or fondaparinux: the open-label, randomised, non-inferiority SURPRISE phase 3b trial. Lancet Haematology 2017; 4: 105-113
- 35 Gjöres JE. Surgical therapy of ascending thrombophlebitis in the saphenous system. Angiology 1962; 13: 241-243
- 36 Verrel F, Ruppert V, Spengel FA. et al. Stadiengerechte Therapie der aszendierenden Thrombophlebitis. Zentralbl Chir 2001; 126: 531-536
- 37 Noppeney T, Noppeney J, Winkler M. et al. Strategien zur Antikoagulation und Operation bei akuter Thrombophlebitis. Zentralbl Chir 2006; 131: 51-56
- 38 Büller HR, Agnelli G, Hull RD. et al. Antithrombotic therapy for venous thromboembolic disease: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126: 401S-428S
- 39 De Maesseneer MGR. Superficial thrombophlebitis of the lower limb: practical recommendations for diagnosis and treatment. Acta Chir Belg 2005; 105: 145-147
- 40 Hach-Wunderle V, Gerlach H, Konstantinides S. et al. Interdisziplinäre S2k-Leitlinie: Diagnostik und Therapie der Bein- und Beckenvenenthrombose und der Lungenembolie: AWMF Leitlinien-Register Nr. 065/002. Vasa 2016; 45 (Suppl. 90) 1-48
- 41 Jacobs B, Coleman DM. Superficial thrombophlebitis. In: Gloviczki P. (ed.): Handbook of venous and lymphatic disorders. 4th edition. CRC Press; 2017
- 42 Mustonen P. Superficial venous thrombophlebitis. EBM Guidelines. Article ID: ebm00920 (005.035) © 2020 Duodecim Publishing Company Ltd
- 43 Kakkos SK, Gohel M, Baekgaard N. et al. European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg 2021; 61: 9-82
- 44 Cosmi B. Risk factors for recurrent events in the subjects with superficial vein thrombosis in the randomized clinical trial SteFlux (Superficial Thromboembolism Fluxum). Thrombosis Research 2014; 133: 196-202