VENOUS DISEASE

Superficial Thrombophlebitis A benign disorder characterized by erythema, tenderness, and edema along involved vein. Conservative therapy includes local heat, elevation, and anti-inflammatory drugs such as aspirin. More serious conditions such as cellulitis or lymphangitis may mimic this, but these are associated with fever, chills, lymphadenopathy, and red superficial streaks along inflamed lymphatic channels.

Deep-Vein Thrombosis (DVT) 

This is a more serious condition that may lead to pulmonary embolism . Particularly common in pts on prolonged bed rest, those with chronic debilitating disease, and those with malignancies .

History 

Pain or tenderness in calf or thigh, usually unilateral; may be asymptomatic, with pulmonary embolism as primary presentation.

Physical Examination 

Often normal; local swelling or tenderness to deep palpation may be present over affected vein.

Laboratory 

d-Dimer testing is sensitive but not specific for diagnosis. Most helpful noninvasive testing is ultrasound imaging of the deep veins with Doppler interrogation [most sensitive for proximal (upper leg) DVT, less sensitive for calf DVT]. Invasive venography is rarely indicated. MRI may be useful for diagnosis of proximal DVT and DVT within the pelvic veins or in the superior or inferior vena cavae.

Venous Disease TREATMENT

Systemic anticoagulation with heparin [5000- to 10,000-U bolus, followed by continuous IV infusion to maintain aPTT at 2 × normal (or using a nomogram: 80-U/kg bolus followed by initial infusion of 18 (U/kg)/h)] or low-molecular-weight heparin (LMWH) (e.g., enoxaparin 1 mg/kg SC bid), followed by warfarin PO (overlap with heparin for at least 4–5 days and continue for at least 3 months if proximal deep veins involved). Adjust warfarin dose to maintain prothrombin time INR 2.0–3.0.

DVT can be prevented by early ambulation following surgery or with low-dose unfractionated heparin during prolonged bed rest (5000 U SC bid-tid) or LMWH (e.g., enoxaparin 40 mg SC daily), supplemented by pneumatic compression boots. Following knee or hip surgery, warfarin (INR 2.0–3.0) is an effective regimen. LMWHs are also effective in preventing DVT after general or orthopedic surgery.