BMJ Best Practice

治疗步骤

Superficial vein thrombophlebitis (SVT) has traditionally been considered a relatively benign condition, with conservative management recommended, mainly focusing on relief of local symptoms. However, since the recognition of the important association between SVT and venous thromboembolism (VTE; includes deep vein thrombosis [DVT] and pulmonary embolism [PE]), antithrombotic treatments aimed at preventing thrombus extension and recurrence such as unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux, and oral anticoagulants have been proposed. Several studies report that, in patients with SVT, especially SVT of the main trunk of the saphenous vein, 6% to 44% of cases are associated with DVT, 20% to 33% are associated with asymptomatic PE, and 2% to 13% are associated with symptomatic PE.[6][15][38][40][42][46][51][52][53] Moreover, retrospective studies report an increased risk of subsequent VTE complications in patients with untreated SVT (1.7% to 26.9% risk of VTE within 3 months).[8][42][51][54] 因此，有越来越多的共识指出，治疗方法不应仅限于解决或改善局部症状，还要防止 SVT 扩展和血栓栓塞并发症。

组织病理学检查显示 SVT 的静脉存在炎症样改变、纤维蛋白沉积和血栓形成。[14] As a result, the mainstay of SVT treatment has traditionally included non-steroidal anti-inflammatory drugs (NSAIDs), although NSAIDs should not be given in combination with anticoagulants due to the increased risk of bleeding. For cases with a high risk of thrombus progression into the deep venous system and embolisation, anticoagulants and surgical treatments have been employed to target the coagulation cascade and, in the case of surgical treatment, to interfere with thrombus development.[4]

常规方法

Though there is no consensus on how best to approach the treatment of SVT, anticoagulants are increasingly being considered the most effective at treating symptoms and preventing SVT extension, SVT recurrence, and VTE complications. Agents aimed at relieving local symptoms, such as compression stockings and topical treatments, have more of an ancillary role in the treatment of SVT as they have little impact on preventing SVT extension and thromboembolic complications. One local guideline has recommended prophylactic anticoagulation for all patients with a superficial thrombus ≥5 cm in length, or within 3 to 5 cm of the saphenofemoral junction.[48] Additionally, an individualised approach is suggested, in which patients with at least one risk factor for VTE may benefit from prophylactic anticoagulation regardless of the length of the thrombus or its proximity to the saphenofemoral junction. This decision should be made through risk-benefit analysis as well as through shared decision making, with respect to patient preference. If the decision is made not to treat a patient with at least one risk factor for VTE, then a repeat duplex scan 7 to 10 days later is recommended.[48]

NSAIDs alone may be an alternative to anticoagulants as they have been shown in a small number of studies to prevent SVT extension when compared with placebo, and to have a similar reduction in the incidence of thromboembolic events as LMWH.[51][54][55] However, NSAIDs should not be prescribed in patients at higher risk of thromboembolism (e.g., extensive SVT with involvement above the knee, particularly if within 2 cm of the saphenofemoral junction; thrombus ≥5 cm in length; severe SVT symptoms; involvement of the greater saphenous vein; history of venous thrombosis or SVT; active cancer) and should not be given in combination with anticoagulants due to the increased risk of bleeding.

外科干预来减轻局部症状和预防SVT扩展和血栓栓塞并发症并没有得到充分的研究。对于禁忌使用抗凝治疗（活动性出血、严重的血小板减少症）的患者，如因血栓位置有血栓栓塞风险，可考虑采用股隐静脉离断术。

伴有感染的浅静脉炎，例如静脉导管部位的静脉炎，被称为感染性血栓性静脉炎。此类临床情况所需治疗方法不同于无菌静脉炎（或SVT）。如果怀疑有脓毒症（感染）性静脉炎或化脓性静脉炎（发生菌血症的静脉炎），就应该考虑使用抗生素。经验性抗生素治疗外周静脉化脓性血栓性静脉炎应该包括对葡萄球菌敏感的药物以及对肠杆菌敏感的药物。抗生素应该根据培养结果和药敏数据调整使用。

大多数针对治疗 SVT 的已有证据都涉及下肢的血栓形成。最近一项关于由静脉内插管引起的上肢 SVT 的 Cochrane 评价发现，治疗这种疾病的证据很少，并且质量较低。[56] 没有足够的数据可评估局部治疗、全身性抗凝治疗或非甾体抗炎药对上肢 SVT 的安全性和有效性。[56]

Anticoagulation

2012 年美国胸科医师学会 (American College of Chest Physicians, ACCP) 的 VTE 疾病抗血栓形成治疗指南[57] 建议 SVT 患者使用预防性剂量或中等剂量的低分子肝素，或者预防剂量的磺达肝素治疗 45 天；[4]证据 null 也有一些较弱的证据证明，SVT可用中等剂量普通肝素治疗45天。[57] 中间剂量大于预防剂量，小于治疗剂量。该 ACCP 指南在 2016 年进行了更新，但更新内容不包括 SVT 患者的 VTE 预防。[58] 其他指南指出，除非有禁忌，否则磺达肝素可能优于 LMWH 或普通肝素 (UFH)。[48] As an alternative to UFH or LMWH or fondaparinux, warfarin can be overlapped with 4 days of UFH or LMWH and continued for 45 days. A repeat Doppler ultrasonography 7 to 10 days following start of anticoagulant therapy may be required to assess for SVT extension, especially in cases of proximal greater saphenous vein SVT treated with intermediate or prophylactic doses of LMWH, prophylactic doses of fondaparinux, or intermediate doses of UFH.

If there is extension, then anticoagulation with a direct oral anticoagulant (DOAC; e.g., dabigatran, rivaroxaban, edoxaban, or apixaban) or warfarin (overlapped with 4 days of treatment-dose, weight-adjusted, LMWH or UFH) for at least 3 months is recommended.[57][59]

In cases where the thrombus is located <2 cm from the saphenofemoral junction, a DOAC or warfarin (target INR 2.4; range 2.0-3.0; overlapped with 4 days of treatment-dose, weight-adjusted, LMWH or UFH) may be considered for a duration of at least 3 months. In patients with SVT and concomitant DVT or PE, first-line therapy includes treatment doses of a DOAC, LMWH, UFH, or fondaparinux, followed by warfarin to target INR 2.5. Ligation with or without thrombectomy can also be considered.

In an open-label randomised trial of patients with SVT at high risk of VTE complications (above-knee SVT and age over 65 years, male sex, previous VTE, cancer, autoimmune disease, or SVT of non-varicose veins), rivaroxaban was non-inferior to fondaparinux with respect to a composite outcome of symptomatic DVT or PE, progression or recurrence of superficial vein thrombosis, and all-cause mortality at 45 days.[59]

A thorough assessment of bleeding risk should be undertaken before prescribing an anticoagulant. Surveillance for heparin-induced thrombocytopenia may be necessary in some cases.

外科干预：隐股静脉瓣连接离断（例如，结扎）

2012 年 ACCP 指南建议，相比手术治疗，优选抗凝剂药物治疗。[57] This recommendation is based on studies that compared surgical therapy with anticoagulation and showed similar rates of SVT progression but higher rates of complications with surgical therapy, such as wound infections.[8] However, in cases where the thrombus is located <2 cm from the saphenofemoral junction, or where the thrombus is free-floating in the common femoral vein and there are contraindications to anticoagulation (active bleeding, severe thrombocytopenia), then ligation with or without thrombectomy can be considered. Once there is no longer a contraindication to anticoagulation, LMWH or UFH should be started or resumed in order to prevent thromboembolic complications.

非甾体抗炎药 (NSAID)

Oral NSAIDs, usually in combination with elastic bandages or compression stockings, can be considered as first-line therapy for SVT that involves tributaries of varicose veins, and in cases where the affected saphenous vein is short in length and away from the saphenofemoral junction.[57][60] Oral NSAIDs, when compared with placebo, have been shown to help with local symptoms and to prevent SVT extension or recurrence.[51][61] 然而，在开具非甾体抗炎药时，应该考虑其禁忌症（如消化性溃疡），并进行临床或者多普勒超声随访，以确定是否有病变扩展。此外，非甾体抗炎药不应该与全身性抗凝治疗同时使用或作为全身性抗凝治疗的辅助治疗，因为这种联合应用可能会增加出血的风险。局部使用抗炎药物可能会减轻局部疼痛和炎症表现，尤其是在伴有静脉曲张的小的SVT中，但这种治疗是有争议的。[52][54][62][63][64]

加压疗法：弹性绷带和弹力袜

加压治疗对SVT的治疗以及减轻局部肿胀疼痛等症状是很重要的。加压疗法旨在通过主动或被动的方式减少静脉回流和外围水肿。

  • 非弹性绷带抵抗因肌肉收缩（被动压缩）导致的肌肉体积增加。静止时，绷带提供的压力很小或没有。

  • 弹力袜或长弹力绷带为肌肉提供主动的压力，无论在肢体静息时还是收缩时。

In the acute phase of SVT, bandages can provide relief from symptoms such as itchiness, pain, and swelling, and compression stockings or long stretch bandages can help with resolution of the SVT and prevent chronic swelling. It should be noted that compression therapy has not been shown to prevent SVT extension or thromboembolic complications. A wide range of ready-to-wear stockings is commercially available, enabling a perfect fit in the vast majority of cases. Stockings may also be made to measure. The major limitations to compression therapy are usually poor patient compliance and, in the elderly, difficulty in applying.

An important contraindication to compression therapy includes a systolic arterial pressure at the ankle <80 mmHg or an ankle-brachial pressure index (ABPI) <0.8. An ABPI of 0.5 to 0.8 indicates that arterial disease may be present and that compression may further compromise arterial blood supply. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

局部热敷和抬高腿

Although there is no evidence for its therapeutic efficacy, local heat application and leg elevation can be used as an ancillary treatment for SVT. Patients should be encouraged to ambulate and to elevate the affected leg when resting. These strategies have not been shown to prevent thromboembolic complications, but they are reasonable to recommend to all patients for symptom relief.

局部治疗

目前没有足够的数据可评估局部治疗对 SVT 的安全性和有效性。[56] A number of randomised trials have evaluated the use of topical treatments in the treatment of upper-extremity thrombophlebitis from catheterisation. Several studies reported significant improvements in signs and symptoms (pain, oedema, erythema) with the use of therapies such as topical heparinoid compared with placebo or no intervention. The level of evidence is low given the small sample sizes and questionable methodological quality of these trials.[56]

静脉曲张手术

在急性治疗某一曲张静脉的SVT，和反复发作的情况下，静脉曲张的手术（结扎和剥离受累血管）可能有效。应遵循静脉曲张的手术指南。

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