Treatment of thrombophlebitis of the lower extremities

Many people who have encountered this widespread vascular pathology are interested in whether thrombophlebitis goes away without treatment?

The formation of blood clots in veins, which in many cases are caused by abnormalities in blood clotting processes, and venous circulation disorders do not go away without medical intervention. Moreover, superficial thrombophlebitis can transform into a pathology of deep veins and lead not only to chronic venous insufficiency, but also to life-threatening pulmonary embolism. It is also necessary to take into account the high probability of developing such a complication of thrombophlebitis as trophic ulcers. Therefore, it is imperative to treat thrombophlebitis of the lower extremities.

Standard of treatment for thrombophlebitis

Drug therapy with anticoagulant pharmacological agents that prevent further blood clotting is the standard of treatment for thrombophlebitis recognized by European phlebologists. However, in general, the optimal treatment for thrombophlebitis (especially superficial) remains controversial, as evidenced, for example, by Cochrane reviews of clinical trials in the field of phlebology.

The main drugs used to reduce the blood's ability to clot are direct anticoagulants, which can prevent blood clots from forming but do not act directly on the blood clot that is already present in the veins. These drugs are used to treat acute thrombophlebitis and deep vein thrombophlebitis.

When the subcutaneous veins are affected, injections for thrombophlebitis are always prescribed. First of all, Heparin (unfractionated) is administered intravenously as a bolus. The drug works by activating antithrombin III, but this effect is very short-lived. At the same time, among the side hematological effects of Heparin, heparin-induced thrombocytopenia is noted (in almost 6% of cases), predisposing to thrombosis due to the formation of antibodies against heparin when it binds to the platelet factor protein PF4. These antibodies activate platelets, so the blood composition should be monitored. And you should not take non-steroidal anti-inflammatory drugs during treatment with Heparin!

Today, in acute thrombophlebitis of the lower extremities, from the point of view of maximum possible effectiveness and less pronounced side effects, the use of so-called low-molecular (fractionated) heparins is recognized as more justified - Enoxaparin sodium (other trade names Anfibra, Clexane, Gemapaxan, Lovenox), Dalteparin (Fragmina) 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 blood clots with injections for thrombophlebitis with the drug Fondaparinux (Arixtra), which is administered subcutaneously once a day.

No earlier than 72 hours after stopping the administration of Heparin, oral administration (once a day) of vitamin K antagonists is prescribed - antithrombotic drugs of the indirect anticoagulant group. These drugs - Warfarin (Warfarex) or Acenocoumarol - block the blood clotting factor, which is synthesized in the liver with the participation of vitamin K. The dose is determined individually, based on the results of a blood test for prothrombin time; the generally accepted course of treatment is three months.

In some cases, aspirin can be used to thin the blood in superficial vein thrombophlebitis (acetylsalicylic acid inhibits platelet aggregation); its daily dosage ranges from 0.125 to 0.3 g. New anticoagulant drugs include Rivaroxaban (Xarelto), which is prescribed to be taken one tablet (0.01 g) once a day.

In cases of deep vein thrombophlebitis of the lower extremities and pulmonary embolism, and if other medications are ineffective, more aggressive therapy with thrombolytics is required: Streptokinase, Urokinase or Alteplase. When administered intravenously through a drip or through a catheter directly into the blood clot, these drugs dissolve the resulting blood clot. Their use is associated with the 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, nonsteroidal anti-inflammatory drugs (NSAIDs) not only relieve pain and inflammation, but also reduce the risk of superficial thrombophlebitis expanding into the deep vein system similar to low-molecular heparins. Diclofenac or Ketoprofen (one tablet twice a day) are most often recommended.

Antibiotics for thrombophlebitis of the lower extremities

In some medical institutions, antibiotics for thrombophlebitis of the lower extremities are still prescribed to everyone, and empirical therapy is carried out with intramuscular injections of penicillin.

Experts from the Infectious Diseases Society of America (IDSA) clarify that purulent thrombophlebitis of peripheral veins occurs more often in conditions of intravenous catheterization of patients, and signs of inflammation of the veins are a local reaction, and not a systemic response to a bacterial infection. This is why antibiotics for the superficial form of the disease are not included in the mandatory standard of treatment for thrombophlebitis in Western medicine.

But if there is a suspicion of infection, and also when a blood test has shown the presence of bacteria (due to the development of streptococcal inflammation of the lymphatic vessels), then patients are immediately given a drip with Vancomycin. Or Cephalexin or Ceftriaxone are administered intravenously - cephalosporin antibiotics that are active against a wide range of gram-negative microbes.

In recent years, our doctors have begun to use antibiotics less frequently for thrombophlebitis of the lower extremities: when patients have a source of inflammation, open injury, diabetes, rheumatic diseases or HIV.

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Ointments for thrombophlebitis of the lower extremities

When the pathology is localized in the subcutaneous veins, ointments for thrombophlebitis of the lower extremities are widely used, which should be applied to the skin over the damaged vessel at least twice a day. These are such products as:

• ointments and gels with heparin: Heparin ointment, Heparin-Akrigel, Trombogel, Tromboles, Liogel, Gepatrombin, Lyoton, Viatromb gel-spray. Continuous use of these ointments is allowed for a week, then a consultation with a phlebologist is necessary. Heparin-containing ointments are not prescribed for deep vein thrombophlebitis.
• 5% butadione ointment (relieves pain and reduces the intensity of inflammation).
• Diclofenac ointment (and Diclac, Diclofenacol, Diclovit, etc. containing it relieve pain and inflammation).
• gels with ketoprofen Ketonal or Febrofid (they act similarly).
• drugs based on rutin, which helps reduce blood clotting, relieves swelling and reduces pain: 2% Venoruton gel (Rudozid), Troxerutin (Troxegel) and Troxevasin gels. These drugs are not used in the first three months of pregnancy.

But Vishnevsky ointment is completely unnecessary for thrombophlebitis without trophic ulcers, since it is an antiseptic agent used only for external suppurations, and in addition, birch tar in the ointment irritates the skin.

Also, you should not make hot or alcohol-containing compresses that promote blood flow for thrombophlebitis of the lower extremities; compresses can only be cold (to reduce pain).

Treatment of ulcers in thrombophlebitis of the lower extremities

In terms of methodology, treatment of ulcers in thrombophlebitis of the lower extremities is not much different from the treatment of open wounds and should be carried out according to the rules.

First, it is necessary to kill the pathogens, for which the doctor prescribes appropriate systemic antibiotics, for example, Clindamycin (150-300 mg 4 times a day).

Necrotic areas must be freed from dead tissue by washing the ulcer 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: Levomekol, Dioxycol, Baneocin, Streptonitol, Methyluracil, synthomycin emulsion, etc. Also, Vishnevsky ointment is still used for thrombophlebitis to cleanse the affected area from pus. All ointments require the application of a bandage with their daily change. There are special ready-made bandages (Proteox, etc.) that accelerate the healing of ulcers.

And the healing of ulcers in thrombophlebitis begins with the basal layers of the skin and subcutaneous tissue - by forming granulation tissue. If this process is too slow (due to insufficient blood supply to the tissues), it can be stimulated a little - use the remedy Kolocil under the bandage, and also take a complex of vitamins A, B1, B2 and B5.

If the ulcer is small, it will heal itself. But if the damage is significant, it may be necessary to close it with a skin flap during plastic surgery.

Surgical treatment of thrombophlebitis of the lower extremities

The decision to perform surgical treatment of thrombophlebitis of the lower extremities is made only for the following indications:

• when a thrombus that has formed in the large external vein of the leg is already found in the large saphenous vein of the thigh, and there is a real danger of it entering the deep veins through the saphenofemoral junction (the so-called ascending thrombophlebitis);
• when there is a risk of a thrombus breaking off and the embolus being carried by the bloodstream into the pulmonary artery with a high probability of its occlusion (thromboembolism);
• when a thrombus becomes purulent and the wall of the vessel to which it is stuck melts, leading to the development of an abscess;
• if several blood clots are found in the deep veins of the leg or thigh;
• provided that the patient does not respond to conservative treatment with anticoagulants;
• if thrombophlebitis develops against the background of oncology.

In modern vascular surgery, surgical treatment of acute thrombophlebitis of the lower extremities includes:

• ligation (crossectomy) of the external vein either above the thrombus or in the area of the saphenofemoral junction;
• endovascular thrombectomy (endoscopic cleaning of veins with a catheter);
• partial closure of the lumen of the affected vessel by stitching or installing a clamp;
• phlebectomy (removal of the affected vein);
• endovascular implantation of a temporary or permanent metal IVC filter inside the inferior vena cava (performed only in cases of high risk of pulmonary embolism to retain large clots until they are destroyed or in cases of acute proximal deep vein thrombosis).

The latter method was introduced in the USA in 2003. During this time, according to the FDA, in 35.6% of operated patients the IVC filter failed to stay in place; in 7.6% the vein perforated; in 15.8% pulmonary embolism developed (despite the filter).

Laser treatment of thrombophlebitis is used to close the vein lumen (obliteration) and prevent the clot from entering the systemic bloodstream. This manipulation is performed endoscopically.

Other methods of treating thrombophlebitis of the lower extremities

Compression of blood vessels with a knitted bandage or special compression hosiery is the standard treatment for thrombophlebitis of the lower extremities all over the world. Such external pressure helps to normalize venous blood transit and improves the well-being of patients. Doctors select the necessary compression class of products: Class 1 - 18-22 mm Hg; Class 2 - 23-32 mm Hg; Class 3 -34-46 mm Hg; Class 4 - more than 49 mm Hg. Any special hosiery is put on immediately after waking up in the morning, in a lying position.

After the acute period of thrombophlebitis, physiotherapeutic procedures are prescribed: UHF, electrophoresis or iontophoresis (with heparin and other drugs), magnetic therapy, etc. Regular massage for thrombophlebitis of the lower extremities is contraindicated, but sessions of hardware pneumatic massage can be prescribed to relieve severe leg swelling.

Hirudotherapy for thrombophlebitis has been used for a long time and successfully, and it relieves pain and constant tension in the legs. And thanks to hirudin, an anticoagulant enzyme in leech saliva that allows it to feed on blood, their use also has a thrombolysis effect, that is, the gradual resorption of clots. By the way, you can use a gel based on hirudin - Girudoven.

Homeopathy for the treatment of thrombophlebitis of the legs offers the preparations Varipulsum (with arnica, lycopodium, sulfur and zinc), Venopulsaninum and Plebohamum. And for the treatment of trophic ulcers there are such means for reducing suppuration as Arnica, Lachesis and Hepar sulfuris. Therapeutic physical training, that is, gymnastics for thrombophlebitis of the lower extremities (naturally, when the acute stage passes), suggests a light load, for example, measured walking over short distances.

Gymnastics for thrombophlebitis of the lower extremities

The basic position for performing the recommended exercises is lying down. Usually they start with "unloading" the legs, for which a pillow is placed so that not only the feet but also part of the shin are on it.

In this position, you need to alternately move your feet “inward and away from you” (slowly); then bend and straighten your toes.

The next exercise involves alternately bending your legs at the knee joints. After that, we complicate the task: the leg bent at the knee must be pulled up to the chest (without raising the head). Each leg performs the exercise 5-6 times.

And when performing the next exercise, the leg bent at the knee and brought closer to the chest must be straightened upwards; then bent again to the chest and straightened horizontally (5 times with each leg).

As a break, you can lie down for a minute with your legs straight (your feet and shins remain elevated). And again, an exercise for your feet: simultaneous rotational movements towards each other, and then in opposite directions.

Now you need to take the pillow out from under your feet, bend your legs at the knees and squeeze the pillow between them, which you need to squeeze and unclench up to 10-12 times, straining your thigh muscles. And the last exercise in a lying position is the well-known "bicycle".

We sit down, slowly lowering our legs to the floor, and in this position we simply need to bend and straighten our legs at the knees (alternately with each leg).

We stand up just as slowly, and in a standing position we begin to roll on our feet from heel to toe and back (12-15 times).

Traditional treatment of thrombophlebitis of the lower extremities

For the most part, folk treatment of thrombophlebitis offers means of healing leg ulcers. Thus, for washing ulcers, it is recommended to use a decoction of plantain leaves or calendula flowers; for drying a wet ulcer, treat it with a solution of burnt alum, propolis or mumiyo (3 g per half a glass of boiled water).

Treatment of thrombophlebitis with soda is also suggested - in the form of compresses with grated raw potatoes (to dry out the ulcer). And for the tightening surface, sea buckthorn oil mixed with a few drops of essential oils of tea tree, geranium or St. John's wort is suitable.

Treatment of thrombophlebitis with aloe involves irrigating the ulcer with fresh juice of the plant, as well as applying dressings soaked in it to the wound.

In thrombophlebitis, herbal treatment is widely used, decoctions of which should be used in the form of compresses and lotions. These are wormwood (contains the natural antibiotic chamazulene and the antiseptic cineole) and chicory (cleans purulent foci due to the glycoside antibin). Comfrey root (in the form of lotions with a decoction - 15 g per 200 ml of water) promotes the regeneration of damaged tissue. Madder roots are rich in phenolic acids and anthracene aglycones, which also exhibit antibacterial properties.

Doctors have long recommended taking an aqueous infusion of sweet clover grass internally (twice a day, 100-150 ml): this plant contains coumarin lactone and dicoumarin, which prevent blood clotting.

And an alcohol tincture from the peel of horse chestnut fruits can slow down the aggregation of blood platelets - due to the esculin and fraxin in its composition. It is enough to take 15 drops twice a day. White willow bark also has anticoagulant properties, containing phenolic glycosides such as salicin and salicortin. In fact, more than 120 years ago, Aspirin was synthesized from willow bark.

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Copper in the treatment of thrombophlebitis

Copper in the treatment of thrombophlebitis is suggested to be used with the help of... a copper coin or a small copper plate, which should be placed in the shoe so that when walking the metal touches the heel. Allegedly, all the symptoms of the disease go away from this. No one undertakes to explain the mechanism of action of the copper coin on the formation of blood clots in the veins of the legs or on the strengthening of venous circulation.

It is known that copper is involved in the formation of red blood cells and the production of oxygen-carrying hemoglobin. But in thrombophlebitis, an important factor is the condition of the vascular walls, that is, sufficient production of elastin (tropoelastin) that forms their fibrous tissues. To synthesize this protein, a catalyst for the "cross-linking" of amino acids is needed - the extracellular peptide lysyl oxidase, which contains a metalloprotein with an active Cu+2 ion in its complex cyclic structure.

Of course, copper from a coin placed under the heel will not enter the body! But food products will help to replenish the "copper reserves". Of the plant products, the richest in Cu are sesame, pumpkin, sunflower, flax and cilantro (coriander) seeds; walnuts, hazelnuts and pine nuts; peanuts and all legumes; buckwheat, millet and oats; champignons and garlic (almost in equal quantities), etc.

For information on what other foods are considered useful for this pathology, see further in the section Diet for thrombophlebitis of the lower extremities.

Treatment of thrombophlebitis in sanatoriums

It is useful for venous circulation and for general health to continue treatment of thrombophlebitis in sanatoriums: three months after stabilization of the condition in the superficial form of the disease and no earlier than six months later in the case of deep vein thrombophlebitis.

Suitable for this purpose are vascular and cardiology health resorts, as well as many multidisciplinary balneological health resorts, where there are hydrogen sulphide mineral waters and muds, carbon dioxide and radon waters.

In this pathology, balneological treatment in the form of baths or water procedures in open water bodies and pools helps to normalize hemodynamics, increase vascular tone and improve the functioning of the entire circulatory system.

The main condition for successful treatment of thrombophlebitis in sanatoriums is the healing of trophic ulcers on the legs. And in case of purulent thrombophlebitis, resorts are contraindicated.

The following sanatoriums provide treatment for thrombophlebitis:

• "Sinyak" (Zakarpattia region, Mukachevo district, village of Sinyak), known outside of Ukraine for its unique hydrogen sulphide water.
• Pirogov Sanatorium (Odessa, Limannaya Street), where treatment is carried out using therapeutic mud and brine from the Kuyalnitsky Estuary.
• "Khmelnik" (Vinnytsia region, Khmelnik city, Kurortnaya street, 2), where there are mineral radon waters and peat mud.
• "Lazurny" (Zaporizhzhya region, Berdyansk, Central Boulevard, 4a) offers treatment with sodium chloride mineral water and sulphide-silt mud.
• Clinical sanatorium "Avangard" (Vinnytsia region, Nemyriv, Shevchenko street, 16) is known for its patented method of volumetric pneumatic pressing on the venous system, thanks to which the trophism of vascular tissues is restored.
• sanatorium "Eysk" (Russian Federation, Krasnodar Territory, Yeysk, Kommunarov St., 41) specializes in peloiotherapy and mineral baths.
• sanatorium "Victoria" (Stavropol Territory, Essentuki, Pushkin St., 22).
• “Tarkhany” (Stavropol Territory, Pyatigorsk, K. Marx St., 14).
• "Rodnik" (Stavropol region, Pyatigorsk, Gagarin Boulevard, 2).
• Multidisciplinary health resort complex "Svetlana" (Krasnodar Region, Sochi, Kurortny Ave., 75).

Diet for thrombophlebitis of the lower extremities

There is no special diet for patients with thrombophlebitis. But this does not mean that there are no products that are undesirable in the diet for this disease.

Experts from the Academy of Nutrition and Dietetics (USA) note that a diet for thrombophlebitis of the lower extremities is basically impossible. This pathology requires limiting the intake of the main vitamin of blood coagulation – vitamin K – with food.

This vital vitamin has three modifications: K1 (phylloquinone), K2 (menaquinone) and K3 (menadione).

Our main source of blood coagulation vitamin is cabbage (of any variety). Green leafy vegetables (lettuce, spinach, parsley, basil, cilantro) are the richest source of vitamin K1, which provides blood with the ability to clot.

Vitamin K2 helps prevent hardening of the arteries, a common factor in the development of cardiovascular disease, and also preserves 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 animal products.

In Ayurvedic medicine, turmeric, which contains curcumin, which works as an antiplatelet agent, has been used for thousands of years to thin the blood. And according to publications in the European Journal of Nutrition, treatment of thrombophlebitis of the lower extremities can be carried out with natural anticoagulants, consuming products that contain many derivatives of salicylic acid: ginger, cayenne pepper, garlic, onions, paprika, thyme, dill, oregano, grapes and cherries, raspberries and cranberries, strawberries and lingonberries, as well as citrus fruits.

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