Thrombophlebitis of lower extremities

If the lining wall of the endothelial vessels is damaged, the process of formation and destruction of thrombi and the general hemodynamics maintained by him are violated, and this is one of the main conditions for the development of thrombophlebitis. Veins suffer more because more than 60% of the blood is in them. Any damage to the internal tissues of the veins causes an inflammatory reaction with immediate adhesion (clumping) of blood platelets at the site of injury, and this disease is more 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 for the ICD 10 - I80.0-I80.3, I82.1 (class IX).

Causes of thrombophlebitis of lower extremities

The pathogenesis of inflammatory-thrombotic disorders is due to the fact that the blood clot is attached to the inner vein of the vein (intima), which leads to the onset of the inflammatory process in the endothelium.

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

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

The causes of thrombophlebitis of the lower limbs in any case lie in the pathological changes in the endothelium of the veins, since proteins synthesized by the endotheliocytes or in its cells and protein receptors provide a dynamic equilibrium of the entire hemostatic system.

Enumerating possible causes of thrombophlebitis of the lower extremities, including deep veins, experts attribute to them the following risk factors for the onset of this pathology:

• expansion of veins in varicose veins (in 55-60% of patients with varicose veins develop thrombophlebitis over time);
• increased levels of estrogen (in pregnancy, hormonal therapy, prolonged use of oral contraceptives);
• genetically determined violation of blood clotting (deficiency circulating in the blood factor prothrombin complex protein S);
• congenital thrombophilia (a deficiency in blood plasma synthesized by the liver protein-anticoagulant C);
• deficiency of antithrombin III;
• hereditary hypercoagulation (factor V of Leiden);
• autoimmune antiphospholipid syndrome (antiphospholipid antibody syndrome APS or APLS);
• imbalance of platelet-derived growth factor, synthesized by bone marrow cells;
• insufficient heparin synthesis by the liver (heparin-associated thrombocytopenia);
• vasculitis, including Behcet's disease;
• polyarteritis, periarteritis, Buerger's disease;
• systemic lupus erythematosus;
• polycythemia (hyperplasia of bone marrow cell elements);
• damage to the walls of blood vessels with an elevated level of homocysteine in the blood (homocysteinemia);
• hereditary metabolic metabolism (homocystinuria);
• increase in blood levels of lipids (hyperlipidemia); bacterial and fungal infections;
• smoking;
• obesity;
• stroke or heart attack;
• cancer of the pancreas, stomach or lungs (migrating thrombophlebitis);
• elderly age;
• prolonged immobilization of limbs (for example, during bed rest);
• iatrogenic factors (use of anthelmintic remedy levamisole, phenothiazines, cytostatics, etc.).

[1], [2], [3], [4], [5], [6], [7], [8]

Symptoms of thrombophlebitis of lower extremities

The first signs of any thrombophlebitis of the lower extremities are felt by the heaviness in the legs and by their puffiness. Then, redness and soreness of the skin above the affected vessel join them.

Symptoms of thrombophlebitis of the lower extremities in acute form manifest with pain of varying intensity. In cases of acute deep vein thrombophlebitis, severe pain occurs in the area of the affected vessel, cyanosis of the skin, tenderness and development of the edema of the soft tissues to be treated; body temperature can jump to + 39 ° C. In such situations, urgent medical care is required, before the delivery of which the person should be laid and nothing to do without a doctor, so as not to provoke the separation of the blood clot from the vessel wall.

In acute superficial thrombophlebitis of the legs, large subcutaneous veins of the posterior surface of the lower leg and thigh are most often affected, the skin above which first becomes red, and then turns blue. At palpation, the vein is dense and painful, the leg swells, a rise in body temperature is recorded.

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

• painful sensations that increase during movement; with the pain in thrombophlebitis of the lower extremities are aching, bursting, burning; can be felt only along the affected vessel or cover the entire leg;

• unilateral swelling of the soft tissues of the limb;
• along the affected external vein, distinct hyperemia and swelling, skin hot;
• hypersensitivity of the skin on the legs or paresthesia (expressed by numbness and "goose bumps");
• superficial veins are filled with blood;
• the vein can be stretched proximal to the place of attachment of the thrombus to the endothelium;
• change the appearance of the skin on the aching leg: first it is pale, then red or bluish-lilac;
• Presence of a symptom of Pratt (glossy skin).

The most common complications occur with superficial thrombophlebitis of the large saphenous vein or lesion of deep veins. First, there is a disruption of the venous valves, resulting in chronic venous insufficiency (often called post-phlebit or post-thrombotic syndrome). This is expressed by pain in the legs, swelling and paresthesia.

Because of the violation of trophism (nourishment of tissues) as complications, first the eczematous foci on the skin surface can be formed, 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 if the blood clot is separated from the vein wall and enters the bloodstream. In this case, the threat of pulmonary embolism (pulmonary embolism) - with a possible fatal outcome - is absolutely real. According to clinical statistics, most often this risk occurs with thrombophlebitis of the subcutaneous femoral and deep veins. In this case, symptoms of pulmonary embolism are noted in 2-13% of patients, and in the absence of treatment, mortality from it reaches up to 3%.

Classification of thrombophlebitis of lower extremities

For all the multifactority of the pathogenesis of this disease, the classification of thrombophlebitis of the lower extremities takes into account only the localization of pathology and the clinical form of the disease.

Superficial thrombophlebitis of the lower extremities occurs in the large or small subcutaneous veins, less often in the external jugular vein; physicians-phlebologists often define it as thrombophlebitis of the subcutaneous veins of the lower extremities (TPV). 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 large saphenous vein (which accounts for an average of 70% of cases) can progress to a deep venous system.

Thrombophlebitis of the deep veins of the lower extremities (DVT) develops in the veins located between the muscles (for example, in the anterior and posterior tibial, fibular, femoral veins). This type of disease can be referred to as internal thrombophlebitis of the lower extremities.

Both types of thrombophlebitis in almost 57% of cases are diagnosed simultaneously in one patient. Usually they are chronic (swelling and pain expressed slightly with increase after exercise), but differ in 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 examined is the sudden emergence of acute thrombophlebitis of the veins of the lower extremities, which can be both superficial and deep. Pain can develop and progress rapidly within a few hours; In the pathological process, only an isolated segment of the vein may be involved or the entire vessel may be affected. This clinical form of the disease, according to researchers, is most often associated with abnormal hypercoagulability.

If the blood clot and tissues of the wall of the saphenous vein become inflamed and necrotic, purulent melting causes purulent thrombophlebitis of the lower extremities (most often, acute superficial thrombophlebitis is transformed into it). Septic purulent thrombophlebitis can be diagnosed in patients with persistent asymptomatic bacteremia (the presence of bacteria in the blood stream) or having perivascular inflammations.

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

Post-traumatic thrombophlebitis of the lower extremities is the result of fractures of the bones or soft tissue damage, for example, its hypercompression with bruises. In malignant diseases that affect the pancreas or stomach, migrating thrombophlebitis of the legs (Tissot syndrome) can develop with the characteristic appearance of small thrombi in various places of superficial veins.

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

[9], [10]

Diagnosis of thrombophlebitis of lower extremities

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

Modern diagnostics of thrombophlebitis of the lower extremities includes blood tests, including coagulogram of blood - examination of folding and determination of serum levels of platelets, fibrinogen, antithrombin, etc. Also a blood test is used to detect antibodies to phospholipids.

A detailed instrumental diagnostics is carried out with the help of:

• contrasting angiography,
• Ultrasound of thrombophlebitis of the inferior extremities - ultrasound dopplerography and duplex (simultaneously in two ultrasound regimens) angioscaning of veins of both legs. Duplex ultrasound reveals the presence, location and extent of venous thrombosis, and also provides an opportunity to establish the presence of other pathologies that can be a source of patient complaints.

An ultrasound scan of the chest is also prescribed to avoid the presence of a thrombus in the pulmonary artery: according to some data, asymptomatic pulmonary embolism is found in 24% of patients.

In thrombophlebitis, differential diagnosis is necessary to distinguish them from pathologies such as lymphangitis, neuritis, rupture of the median gastrocnemius muscle, tendonitis, lipodermatosclerosis, lymphedema, etc.

[11], [12], [13], [14], [15], [16]

Treatment of thrombophlebitis of lower extremities

For the vast majority of patients with superficial disease localization (TPV), treatment of thrombophlebitis of the lower extremities is symptomatic and consists of the administration of non-steroidal anti-inflammatory drugs such as Ibuprofen - to reduce pain and relieve inflammation; reception of anticoagulants (Warfarin or Heparin) - to prevent the formation of new blood clots; intravenous injection of thrombolytic agent Streptokinase (Altipase) - to dissolve an existing thrombus; support of veins with compression knitwear or bandaging of legs with 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 a heparin ointment on the skin and do not keep your legs in the lowered position.

In each case, the risk factors of the individual patient, including coagulation disorders or malignancies, should be considered, and this allows individualization of the treatment plan.

In some situations, a phlebologist may be recommended surgical treatment of thrombophlebitis of the lower limbs, up to removal of the damaged segment of the vein.

The recommended preventive medicine aims to minimize the effect of factors contributing to the formation of blood clots in the veins. To do this, you need to walk more and generally move, lose weight, do not wear tight clothes, do not sit and stand for a long time. What else can we do? Look again at the section Causes of thrombophlebitis of the lower extremities, and perhaps your list of preventive measures will expand ...

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