Thrombophlebitis of the lower extremities

When the endothelium lining the walls of blood vessels is damaged, the process of thrombus formation and destruction supported by it and the general hemodynamics are disrupted, and this is one of the main conditions for the development of thrombophlebitis. Veins suffer the most, since more than 60% of the blood is located in them. Any damage to the internal tissues of the veins causes an inflammatory reaction with immediate adhesion (sticking together) of blood platelets at the site of damage, and this disease is most often localized in the vessels of the legs and is called thrombophlebitis of the lower extremities. This is a disease of the circulatory system, the code according to ICD 10 is I80.0-I80.3, I82.1 (class IX).

Causes of thrombophlebitis of the lower extremities

The pathogenesis of inflammatory-thrombotic disorders is associated with the fact that a blood clot attaches to the inner lining of the vein (intima), which leads to the onset of an inflammatory process in the endothelium.

Superficial thrombophlebitis of the lower extremities can occur spontaneously or as a complication of medical intervention (for example, with intravenous infusion).

Although the true etiology often remains unclear, thrombophlebitis of the lower extremities affecting the superficial veins is usually associated with one of the components of the so-called Virchow's triad, namely: damage to the intima (which can be caused by trauma and infection); a decrease in the velocity of venous blood flow or blood stagnation; changes in the composition of the blood with an increase in its procoagulant factors that increase coagulability (thrombospondin, endothelin, fibronectin, plasminogen activator, etc.), or a decrease in anticoagulant factors (prostacyclin, thrombomodulin, etc.).

The causes of thrombophlebitis of the lower extremities in any case are rooted in pathological changes in the venous endothelium, since proteins and protein receptors synthesized by endothelial cells or located in its cells ensure the dynamic balance of the entire hemostasis system.

Listing the possible causes of thrombophlebitis of the lower extremities, including deep veins, experts include the following risk factors for the occurrence of this pathology:

• dilation of veins with varicose veins (55-60% of patients with varicose veins eventually develop thrombophlebitis);
• increased estrogen levels (during pregnancy, hormone therapy, long-term use of oral contraceptives);
• genetically determined blood clotting disorder (deficiency of the prothrombin complex protein S factor circulating in the blood);
• congenital thrombophilia (deficiency in the blood plasma of the anticoagulant protein C synthesized by the liver);
• antithrombin III deficiency;
• hereditary hypercoagulability (factor V Leiden);
• autoimmune antiphospholipid syndrome (antiphospholipid antibody syndrome APS or APLS);
• imbalance of platelet-derived growth factor synthesized by bone marrow cells;
• insufficient synthesis of heparin by the liver (heparin-associated thrombocytopenia);
• vasculitis, including Behcet's disease;
• polyarteritis, periarteritis, Buerger's disease;
• systemic lupus erythematosus;
• polycythemia (hyperplasia of bone marrow cellular elements);
• damage to the walls of blood vessels due to elevated levels of homocysteine in the blood (homocysteinemia);
• hereditary disorder of methionine metabolism (homocystinuria);
• increased blood lipid levels (hyperlipidemia); bacterial and fungal infections;
• smoking;
• obesity;
• stroke or heart attack;
• pancreatic, stomach or lung cancer (migratory thrombophlebitis);
• old age;
• long-term immobilization of limbs (for example, during bed rest);
• iatrogenic factors (use of the anthelmintic drug levamisole, phenothiazines, cytostatics, etc.).

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Symptoms of thrombophlebitis of the lower extremities

The first signs of any thrombophlebitis of the lower extremities are felt as heaviness in the legs and their swelling. Then they are joined by redness and soreness of the skin over the affected vessel.

Symptoms of acute thrombophlebitis of the lower extremities manifest as pain of varying intensity. In cases of acute thrombophlebitis of deep veins, severe pain occurs in the area of the affected vessel, the skin becomes cyanotic, painful, and edema of the underlying soft tissues develops; body temperature can jump to +39°C. In such situations, urgent medical care is required, before which the person must be laid down and nothing should be done without a doctor, so as not to provoke the detachment of the blood clot from the vessel wall.

In acute superficial thrombophlebitis of the legs, the large subcutaneous veins of the back of the shin and thigh are most often affected, the skin above which first becomes red and then blue. When palpated, the vein is dense and painful, the leg swells, and an increase in body temperature is recorded.

In clinical phlebology, the following typical symptoms of thrombophlebitis of the lower extremities are noted:

• pain that increases with movement; in this case, pain in thrombophlebitis of the lower extremities can be aching, bursting, burning; it can be felt only along the affected vessel or affect the entire leg;

• unilateral swelling of the soft tissues of the limb;
• along the affected external vein there is distinct hyperemia and swelling, the skin is hot;
• hypersensitivity of the skin on the legs or paresthesia (expressed by numbness and “goosebumps”);
• superficial veins are filled with blood;
• the vein may be stretched proximal to the site of thrombus attachment to the endothelium;
• change in the appearance of the skin on the affected leg: at first it is pale, then red or bluish-purple;
• presence of Pratt's symptom (glossy appearance of the skin).

The most common complications occur with superficial thrombophlebitis of the great saphenous vein or damage to deep veins. First, there is a disruption of the venous valves, resulting in chronic venous insufficiency (often called postphlebitic or postthrombotic syndrome). This is expressed by pain in the legs, swelling and paresthesia.

Due to the disruption of trophism (tissue nutrition), complications may first form in the form of eczematous lesions on the surface of the skin, and then, in their place, trophic ulcers appear with thrombophlebitis of the lower extremities (in 10-15% of cases).

The most dangerous consequences of this disease can be when a blood clot breaks away from the vein wall and enters the bloodstream. In this case, the threat of pulmonary embolism (thromboembolism of the pulmonary artery) - with a possible fatal outcome - is absolutely real. According to clinical statistics, this risk most often occurs with thrombophlebitis of the subcutaneous femoral and deep veins. In this case, symptoms of pulmonary embolism are observed in 2-13% of patients, and in the absence of treatment, mortality from it reaches 3%.

Classification of thrombophlebitis of the lower extremities

Despite the multifactorial nature of the pathogenesis of this disease, the classification of thrombophlebitis of the lower extremities takes into account only the localization of the pathology and the clinical form of the disease.

Superficial thrombophlebitis of the lower extremities occurs in the great or small saphenous veins, less often in the external jugular vein; phlebologists often define it as thrombophlebitis of the saphenous veins of the lower extremities (SVL). According to long-term observations, superficial thrombophlebitis in the absence of varicose veins develops relatively rarely (5-10% of all cases). Specialists note that thrombophlebitis of the great saphenous vein (which accounts for an average of 70% of cases) can progress to the deep venous system.

Deep vein thrombophlebitis of the lower extremities (DVT) develops in the veins located between the muscles (for example, in the anterior and posterior tibial, peroneal, femoral vein). This type of disease can be called internal thrombophlebitis of the lower extremities.

Both types of thrombophlebitis are diagnosed simultaneously in one patient in almost 57% of cases. They are usually chronic (swelling and pain are slightly expressed with an increase after physical exertion), but are characterized by a recurrent course (in 15-20% of cases). Therefore, there is a periodic exacerbation of thrombophlebitis of the lower extremities - with an increase in the manifestation of symptoms.

Separately, we consider suddenly occurring acute thrombophlebitis of the veins of the lower extremities, which can be both superficial and deep. Pain can develop and progress rapidly over several hours; the pathological process can involve only an isolated segment of the vein or affect the entire vessel. According to researchers, this clinical form of the disease is most often associated with pathological hypercoagulation.

If the blood clot and the tissues of the wall of the subcutaneous vein become inflamed and undergo necrosis, their purulent melting causes purulent thrombophlebitis of the lower extremities (most often, acute superficial thrombophlebitis transforms into it). Septic purulent thrombophlebitis can be diagnosed in patients with persistent asymptomatic bacteremia (the presence of bacteria in the bloodstream) or with perivascular inflammation.

Traumatic (chemical) thrombophlebitis of the lower extremities is considered to be thrombophlebitis that develops after sclerotherapy used to treat varicose veins.

Posttraumatic thrombophlebitis of the lower extremities is a consequence of bone fractures or soft tissue damage, for example, its hypercompression during bruises. In malignant diseases affecting the pancreas or stomach, migrating thrombophlebitis of the legs (Trousseau syndrome) can develop with the characteristic appearance of small blood clots in different places of the superficial veins.

Surgeons also divide thrombophlebitis of the lower extremities depending on the absence or presence of varicose veins.

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Diagnosis of thrombophlebitis of the lower extremities

The appearance of veins during their simple visual inspection and palpation is not a 100% reliable method for determining the state of the peripheral venous system, since such clinical signs as erythema, swelling and pain are common to many other diseases of the lower extremities.

Modern diagnostics of thrombophlebitis of the lower extremities includes blood tests, including a blood coagulogram - a study of coagulability and determination of serum levels of platelets, fibrinogen, antithrombin, etc. A blood test is also taken to detect antibodies to phospholipids.

A comprehensive instrumental diagnostics is carried out using:

• contrast angiography,
• Ultrasound of thrombophlebitis of the lower extremities - ultrasound Dopplerography and duplex (simultaneously in two ultrasound modes) angioscanning of the veins of both legs. Duplex ultrasound reveals the presence, location and degree of venous thrombosis, and also makes it possible to establish the presence of other pathologies that may be the source of the patient's complaints.

An ultrasound scan of the chest is also prescribed to check for the presence of a blood clot in the pulmonary artery: according to some data, asymptomatic pulmonary embolism is detected in 24% of patients.

In thrombophlebitis, differential diagnostics are necessary to distinguish it from such pathologies as lymphangitis, neuritis, rupture of the medial head of the gastrocnemius muscle, tendinitis, lipodermatosclerosis, lymphedema, etc.

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Treatment of thrombophlebitis of the lower extremities

For the vast majority of patients with superficial localization of the disease (SLT), treatment of lower extremity thrombophlebitis is symptomatic and consists of taking non-steroidal anti-inflammatory drugs such as Ibuprofen to reduce pain and relieve inflammation; taking anticoagulants (Warfarin or Heparin) to prevent the formation of new blood clots; intravenous injections of the thrombolytic agent Streptokinase (Altipase) to dissolve an existing clot; supporting the veins with compression hosiery or bandaging the legs with an elastic bandage to reduce discomfort. If there is evidence of infection, a short course of antibiotics may be prescribed.

It is also recommended to make warm compresses with magnesium sulfate, apply heparin ointment to the skin and not keep your legs in a lowered position.

In each case, individual patient risk factors, including coagulation disorders or malignancies, must be considered, allowing for individualization of the treatment plan.

In some situations, a phlebologist may recommend surgical treatment of thrombophlebitis of the lower extremities, including removal of the damaged section of the vein.

The prevention recommended by doctors aims to minimize the effects of factors that contribute to the formation of blood clots in the veins. To do this, you need to walk more and move around in general, lose excess weight, not wear tight clothes, and not sit or stand for long periods of time. What else can we do? Take another look at the Causes of Thrombophlebitis of the Lower Extremities section, and perhaps your list of preventive measures will expand...

And if you treat thrombophlebitis of the lower extremities according to all the rules, then its prognosis can be quite acceptable, if you do not pay attention to complications, or rather, try to avoid them.