The standard of thrombophlebitis treatment
Drug therapy with the help of anticoagulant pharmacological agents that prevent further blood clotting is a standard of treatment for thrombophlebitis recognized by European phlebologist physicians. However, in general, the optimal treatment of thrombophlebitis (especially, superficial) remains controversial, as evidenced, for example, by the Cochrane reviews of clinical studies in the field of phlebology.
The main drugs used to reduce the ability of blood to clot - direct anticoagulants - can prevent the formation of blood clots, but do not directly affect the blood clot existing in the veins. Preparations of this pharmacological group are used in the treatment of acute thrombophlebitis and deep vein thrombophlebitis.
When the subcutaneous veins are affected, injections are always administered with thrombophlebitis. First of all, a heparin (unfractionated) is injected into the vein in a bolus. The drug works by activating antithrombin III, but this action is very short. Heparin-induced thrombocytopenia (almost in 6% of cases), predisposing to thrombosis due to the formation of antibodies against heparin, when it binds to the platelet factor protein PF4, is noted among heparin's hematologic side effects. These antibodies activate platelets, so the composition of the blood should be monitored. And you should not take non-steroidal anti-inflammatory drugs during the treatment with Heparin!
To date, with acute thrombophlebitis of the lower extremities, the use of so-called low molecular weight (fractionated) heparins - Enoxaparin sodium (other trade names Anfibra, Clexane, Hemapaksan, Lovenox), Dalteparina, is more justified in terms of the highest possible efficacy and less pronounced side effects. (Phragmina) or Tinzaparin. These drugs are administered subcutaneously (into the peritoneum) 1-2 times during the day.
Helps reduce the synthesis of coagulation factor II (thrombin) and prevents the formation of thrombotic pricks with thrombophlebitis with Fondaparinux (Arikstra), which is administered subcutaneously once a day.
Not earlier than 72 hours after stopping the administration of Heparin, oral administration (once a day) of vitamin K antagonists - antithrombotic agents of a group of indirect anticoagulants is prescribed. These medications - Warfarin (Warfarex) or Acenocoumarol - block the blood coagulation factor, which is synthesized in the liver with the participation of vitamin K. The dose is determined individually, according to the results of a blood test for prothrombin time; the standard course of treatment is three months.
Aspirin in thrombophlebitis of superficial veins can in some cases be used to dilute blood (acetylsalicylic acid inhibits platelet aggregation); its daily dosage varies in the range from 0.125 to 0.3 g. The new anti-coagulant drugs include Rivaroxaban (Xarelto), which is supposed to take one tablet (0.01 g) once a day.
With thrombophlebitis of the deep veins of the lower limbs and pulmonary embolism, and if other drugs do not produce an effect, more aggressive thrombolytic therapy is required: streptokinase, Urokinase, or Alteplase. When injected into a vein through a dropper or through a catheter directly into a blood clot, these drugs dissolve the blood clot formed. Their use is associated with a risk of serious bleeding and, as a rule, they are used only in life-threatening situations in the clinical intensive care unit.
As foreign experts note, non-steroidal anti-inflammatory drugs (NSAIDs) not only relieve pain and inflammation, but also reduce the risk of expansion of surface thrombophlebitis into the deep vein system similarly to low-molecular heparins. Most often, Diclofenac or Ketoprofen are recommended (twice a day on a pill).
Antibiotics for thrombophlebitis of lower extremities
In some medical institutions, antibiotics are still prescribed for thrombophlebitis of the lower limbs, and empirical therapy is given in / m injections of penicillin.
Experts of the American Society of Infectious Diseases (IDSA) clarify that purulent thrombophlebitis of peripheral veins occurs more often in conditions of intravenous catheterization of patients, and signs of venous inflammation are a local reaction rather than a systemic response to a bacterial infection. That is why antibiotics for the superficial form of the disease are not included in the mandatory standard of treatment of thrombophlebitis in Western medicine.
But if there is a suspicion of infection, and when a blood test showed the presence of bacteria (due to the development of streptococcal inflammation of the lymphatic vessels), patients are immediately put on a dropper with Vancomycin. Either intravenously injected Cephalexin or Ceftriaxone - antibiotic cephalosporin series, which are active against a wide range of gram-negative microbes.
In recent years, and our doctors, antibiotics with thrombophlebitis of the lower extremities began to go less frequently: when patients have a focus of inflammation, open trauma, diabetes, rheumatic diseases or HIV.
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Ointments with thrombophlebitis of lower extremities
When the pathology is localized in the subcutaneous veins, ointments with thrombophlebitis of the lower extremities are widely used, which should be applied to the skin above the damaged vessel at least twice a day. These are such tools as:
- ointments and gels with heparin: Heparin ointment, Heparin-Acrigel, Thrombogel, Tromboles, Liogel, Hepatrombin, Lyoton, Viatromb spray gel. Continuous use of these ointments is allowed for a week, then consultation with a phlebologist is necessary. Heparin-containing ointments are not prescribed for thrombophlebitis of deep veins.
- 5% butadion ointment (anesthetizes and reduces the intensity of inflammation).
- ointment Diclofenac (and containing it Diklak, Diclofenacol, Diklovit et al. Relieve pain and inflammation).
- Gels with ketoprofen Ketonal or Febrofid (they act similarly).
- drugs on the basis of routine that helps reduce blood clotting, relieves swelling and reduces pain: 2% Venoruton (Rudoside) gel, Troxerutin gels (Troxsegel) and Troxevasin. In the first three months of pregnancy, these funds are not applied.
But Vishnevsky's ointment with thrombophlebitis without trophic ulcers is absolutely unnecessary, because this antiseptic is used only with external suppuration, besides, birch tar in the composition of the oil irritates the skin.
Also, do not make hot blood or alcohol-containing compresses that promote hot flushes with thrombophlebitis of the lower limbs; Compresses can only be cold (to reduce soreness).
Treatment of ulcers with thrombophlebitis of lower extremities
From the point of view of the technique, the treatment of ulcers with thrombophlebitis of the lower extremities differs little from the treatment of open wounds and should be done according to the rules.
First, it is necessary to kill the pathogens of the infection, for which the doctor assigned the appropriate systemic antibiotics, for example, Clindamycin (150-300 mg 4 times a day).
Sites of necrosis are necessarily exempt from dead tissue by washing ulceration with furacilin solution, hydrogen peroxide, chymotrypsin, chlorhexidine, decamethoxin, etc. And only after drying with a sterile napkin can an ointment be applied to the ulcer: Levomecol, Dioksikol, Baneocin, Streptonitol, Methyluracil, emulsion of synthomycin, etc. Also, to cleanse the lesions from pus, Vishnevsky's ointment is still used with thrombophlebitis. All ointments assume the imposition of a bandage with their daily shift. There are special ready-made dressings (Proteox, etc.) that accelerate the healing of ulcers.
A healing of ulcers with thrombophlebitis begins with the basal layers of the skin and subcutaneous tissue - by forming a granulation tissue. If this process is too slow (due to insufficient blood supply of tissues), it can be stimulated a little - use the Kolotsil remedy for the bandage, and also take a complex of vitamins A, B1, B2 and B5.
With a small area of ulcers, she will heal itself. But with significant damage, it may be necessary to close it with a skin flap during plastic surgery.
Operative treatment of thrombophlebitis of lower extremities
The decision to perform surgical treatment of thrombophlebitis of the lower extremities is taken only for such indications:
- when a thrombus formed in the large external vein of the tibia is already found in the large saphenous vein on the thigh, and there is a real danger of its entry through the saphenofemoral fistula into the deep veins (so-called ascending thrombophlebitis);
- when there is a threat of separation of the thrombus and embolus transfer to the pulmonary artery with a high probability of its overlap (thromboembolism);
- with suppuration of the thrombus and melting of the wall of the vessel in which it stuck, with the development of the abscess;
- if several blood clots are found in deep veins of the lower leg or thigh;
- provided that the patient does not perceive conservative treatment with anticoagulants;
- if the development of thrombophlebitis occurs against the background of oncology.
In modern vascular surgery, surgical treatment of acute thrombophlebitis of the lower extremities includes:
- dressing (crossectomy) of the external vein or above the thrombus, or in the area of saphenofemoral anastomosis;
- endovascular thrombectomy (endoscopic cleaning of veins by a catheter);
- partial overlapping of the lumen of the affected vessel by the method of insertion or clamping;
- phlebectomy (removal of the affected vein);
- endovascular implantation of a temporary or permanent metal IVC filter inside the inferior vena cava (only performed with a high risk of pulmonary thromboembolism to delay large clots until they are destroyed or with acute proximal deep vein thrombosis).
The latter method was introduced in the US in 2003. During this time, according to the FDA, in 35.6% of the patients undergoing surgery, the IVC-filter was not kept on site; 7.6% had a perforation of the vein; 15.8% developed a pulmonary thromboembolism (despite the filter).
Treatment of thrombophlebitis with a laser is used to close the lumen of the vein (obliteration) and to prevent the clot from entering the systemic circulation. This manipulation is performed endoscopically.
Other methods of treatment of thrombophlebitis of lower extremities
Vessel compression by a knitted bandage or special compression knitwear is the standard for the treatment of thrombophlebitis of the lower extremities worldwide. Such external pressure contributes to the normalization of the venous transit of blood and improves the health of patients. Doctors select the necessary class of compression of products: Class 1 - 18 -22 mm Hg. P. 2nd class - 23-32 mm Hg. P. Grade 3 -34-46 mm Hg. P. Class 4 - more than 49 mm Hg. Art. Any spetsrikotazh puts on immediately after the morning awakening, in the supine position.
After the lapse of an acute period of thrombophlebitis, physiotherapeutic procedures are prescribed: UHF, electrophoresis or iontophoresis (with heparin and other drugs), magnetotherapy, etc. An ordinary massage with thrombophlebitis of the lower extremities is contraindicated, but for the removal of severe swelling of the legs, sessions of apparatus pneumatic massage may be prescribed.
Hirudotherapy with thrombophlebitis is used long and successfully and relieves pain and constant tension in the legs. And thanks to hirudin - anticoagulant enzyme saliva of leeches, which allows it to feed on blood - their use has the effect of thrombolysis, that is, a gradual resorption of clots. By the way, you can use a gel based on hirudin - Girudoven.
Homeopathy for the treatment of foot thrombophlebitis offers Varipulsum preparations (with arnica, lycopodium, sulfur and zinc), Venopulsaninum and Plebohamum. And for the treatment of trophic ulcers, there are such means to reduce suppuration, like Arnica, Lachesis and Hepar sulfuris. Physiotherapy, that is, gymnastics with thrombophlebitis of the lower extremities (naturally, when the acute stage passes), involves a light load, for example, measured walking over short distances.
Gymnastics with thrombophlebitis of lower extremities
The main position for performing the recommended exercises is lying down. Usually they begin with the "unloading" of the legs, for which the pillow is placed so that not only the feet, but also the shin part, are located on it.
In this position, one should alternately make foot movements "in oneself - from oneself" (slowly); then bend and unbend the toes.
The next exercise consists in alternately bending the legs in the knee joints. After that, we complicate the task: the knee bent at the knee should be pulled to the chest (without lifting the head). Each leg is exercised 5-6 times.
And when performing the next exercise, the leg bent at the knee and approximated to the chest should be straightened upwards; then again bend to the chest and straighten horizontally (each foot 5 times).
As a respite, you can lie for a moment with your legs straight (the feet and shins remain on the dais). And again, the exercise for the feet: simultaneous rotational movement towards, and then - in opposite directions.
Now we need to take out the pillow from under the feet, bend the legs in the knees and hold a pillow between them, which must be squeezed and unclamped 10-12 times, straining the muscles of the thighs. And the last exercise in the prone position is the famous "bike".
We sit down, slowly lowering our legs to the floor, and in this position it is necessary simply to bend and unbend the legs in the lap (alternately with each leg).
Just as slowly get up, and in the standing position we begin to roll on the soles from the heel to the toe and back (12-15 times).
Alternative treatment of thrombophlebitis of lower extremities
For the most part, alternative thrombophlebitis treatment offers the means of healing ulcers on the legs. So, for washing ulcers it is recommended to use decoction of leaves of plantain or calendula flowers; for drying the soaking ulcer - treat it with a solution of burnt alum, propolis or mummy (3 g per half a cup of boiled water).
It is proposed and treatment of thrombophlebitis with soda - in the form of compresses with grated raw potatoes (to dry the ulcer). And for a tight surface, sea buckthorn oil, mixed with a few drops of essential oils of tea tree, geranium or St. John's wort.
Treatment of thrombophlebitis with the help of aloe is the irrigation of ulcers with fresh juice of the plant, as well as the imposition on the wound of the bandages moistened by it.
When thrombophlebitis is widely used treatment with herbs, decoctions of which should be used in the form of compresses and lotions. This wormwood bitter (contains a natural antibiotic chamazulene and antiseptic cineol) and chicory ordinary (clears purulent foci due to glycoside antibin). Promotes the regeneration of damaged tissues comfrey root (in the form of lotions with decoction - 15 g per 200 ml of water). The roots of the madder of the dye are rich in phenolcarbonic acids and anthracene aglycons, which also exhibit antibacterial properties.
Water infusion of herb millet grass has long been recommended for oral use (twice a day for 100-150 ml): this plant contains a lactone of coumarin and dicumarin, which prevent blood clotting.
A spirit tincture from the rind of horse chestnut fruit can slow down the aggregation of blood platelets - due to the available in its composition of esculin and fractine. It is enough to take 15 drops a day twice a day. The cortex of the willow is white, containing phenolic glycosides, such as salicin and salicortin, also have anticoagulant properties. Actually, more than 120 years ago it was from the willow bark that Aspirin was synthesized.
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Copper in the treatment of thrombophlebitis
Copper in the treatment of thrombophlebitis is suggested to be used with ... A copper coin or a small plate of copper, which should be put in shoes, so that when walking metal touches the heel. Like, this leaves all the symptoms of the disease. The mechanism of action of a copper coin to form blood clots in the veins of the legs or to enhance venous circulation is not explained.
It is known that with the participation of copper, the formation of red blood cells also occurs, and the production of oxygen-transporting hemoglobin. But with thrombophlebitis, the important factor is the state of the vascular walls, that is, the sufficient production of the fibrous elastin tissue (tropoelastin) that forms them. To synthesize this protein, a "crosslinking" amino acid catalyst is needed - an extracellular peptide of lysyl oxidase, containing in its complex cyclic structure a metalloprotein with an active Cu + 2 ion.
Of course, copper from a coin, put under the heel, will not get into the body! But replenish the "copper reserves" will help food products. Of the plant products, sesame seeds, pumpkin, sunflower, flax and cilantro (coriander) are the richest in Cu content; greek, forest and cedar nuts; peanuts and all legumes; buckwheat, millet and oats; champignons and garlic (almost in equal quantities), etc.
About what other products are considered useful for this pathology, see further in the Diet section with thrombophlebitis of the lower extremities.
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Treatment of thrombophlebitis in sanatoria
It is useful for venous circulation and for general improvement to continue treatment of thrombophlebitis in sanatoria: three months after stabilization of the condition with a superficial form of the disease and no earlier than six months later with thrombophlebitis of deep veins.
Suitable for this purpose are sanatorium establishments of the vascular and cardiological profile, as well as many multi-disciplinary balneological health resorts, where there are hydrogen sulfide mineral waters and mud, carbonic and radon waters.
With this pathology, balneological treatment in the form of baths or the adoption of water procedures in open reservoirs and basins contributes to the normalization of hemodynamics, increased vascular tone and improvement of the whole circulatory system.
The main condition for the successful treatment of thrombophlebitis in sanatoria is the healing of trophic ulcers on the legs. And with purulent thrombophlebitis resorts are contraindicated.
Thrombophlebitis is treated, such sanatoria as:
- "Bruce" (Transcarpathian region, Mukacheve district, Sinyak village), famous outside of Ukraine for its unique hydrogen sulfide water.
- sanatorium them. Pirogov (Odessa, Limannaya st.), Where the treatment is carried out with therapeutic mud and brine of Kuyalnik estuary.
- "Khmilnik" (Vinnitsa region, Khmilnik, Kurortnaya Str., 2), where there are mineral radon waters and peat mud.
- "Azure" (Zaporozhye region, Berdyansk, Central Boulevard, 4a) offers treatment with chloride-sodium mineral water and sulphide-silt mud.
- Clinical sanatorium "Avangard" (Vinnytsia region, Nemyriv, Shevchenko str., 16) is known for the patented technique of volumetric pneumosuppression on the venous system, thanks to which the trophism of vascular tissues is restored.
- sanatorium "Yeisk" (RF, Krasnodar region, Yeisk, 41, Kommunarov Street) specializes in peloid therapy and mineral baths.
- Sanatorium "Victoria" (Stavropol Territory, Yessentuki, Pushkin Str. 22).
- "Tarkhany" (Stavropol Territory, Pyatigorsk, K. Marx street, 14).
- "Spring" (Stavropol Territory, Pyatigorsk, Gagarin Boulevard, 2).
- multi-profile sanatorium and resort complex "Svetlana" (Krasnodar region, Sochi, Kurortny pr., 75).
Diet with thrombophlebitis of lower extremities
A special diet intended for patients with thrombophlebitis does not exist. But this does not mean that there are no products that are undesirable in the diet for this disease.
Specialists of the Academy of Nutrition and Dietetics (USA) note that a diet with thrombophlebitis of the lower extremities is impossible in principle. This pathology requires a restriction of the intake of the main vitamin of blood coagulation - vitamin K.
This vitally important vitamin has three modifications: K1 (phylloquinone), K2 (menaquinone) and K3 (menadione).
Our main source of vitamin coagulation is the blood of cabbage (any varieties). Green leafy vegetables (salad, spinach, parsley, basil, coriander) are the richest source of vitamin K1, which provides the ability of the blood to curl up.
Vitamin K2 helps prevent hardening of the arteries, which is a common factor in the development of cardiovascular diseases, and also keeps calcium in our bones, protecting against osteoporosis. This vitamin is abundant in fish (sardines, tuna and salmon) and shrimp. But its presence in meat, dairy products and eggs depends on what the cow or chicken was fed: only eating fresh grass ensures the presence of vitamin K2 in foods of animal origin.
In Ayurvedic medicine for blood thinning for millennia used turmeric, which contains curcumin, working as an antiaggregant. And according to the European Journal of Nutrition, the treatment of thrombophlebitis of the lower limbs can also be carried out with natural anticoagulants, using products containing many salicylic acid derivatives: ginger, cayenne pepper, garlic, onion, paprika, thyme, dill, oregano, grapes and cherries, raspberries and cranberries, strawberries and lingonberries, as well as citrus.
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