浅表性血栓性静脉炎

Must be treated according to the venous thromboembolism (VTE) practice guidelines.[57]Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis. 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(suppl 2):e419S-94S.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278049/http://www.ncbi.nlm.nih.gov/pubmed/22315268?tool=bestpractice.com[58]Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315-352.http://www.ncbi.nlm.nih.gov/pubmed/26867832?tool=bestpractice.com

Initial treatment doses of low molecular weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux followed by warfarin to target INR 2.5. Rivaroxaban, dabigatran, apixaban, or edoxaban can also be used for initial treatment.

对于肾脏损害患者（即肌酐清除率＜30 mL/min），首选抗凝剂是普通肝素。

The newer anticoagulants (dabigatran, rivaroxaban, edoxaban, and apixaban) are considered suitable alternatives. However, clinical data on their use in the management of SVT are only available for rivaroxaban.[65]Werth S, Bauersachs R, Gerlach H, et al. Superficial vein thrombosis treated for 45 days with rivaroxaban versus fondaparinux: rationale and design of the SURPRISE trial. J Thromb Thrombolysis. 2016 Aug;42(2):197-204.http://www.ncbi.nlm.nih.gov/pubmed/26973347?tool=bestpractice.com As a result, support for their use in SVT is extrapolated from their use in the management of deep vein thrombosis (DVT).

Dabigatran and edoxaban require lead-in therapy with a parenteral anticoagulant such as UFH or a LMWH for 5 to 10 days before starting therapy, whereas rivaroxaban and apixaban can be initiated as monotherapy with no need for lead-in therapy.

Rivaroxaban, dabigatran, edoxaban, and apixaban are not recommended in patients with hepatic or severe renal impairment.

Rivaroxaban, dabigatran, edoxaban, and apixaban have a rapid onset of action, do not undergo any interactions with food, and are short-acting; however, they do undergo drug interactions and reversal agents may not be available.

应咨询专科医生或根据当地治疗原则指导治疗剂量。

Where anticoagulation is contraindicated, ligation with or without thrombectomy may be indicated, where local expertise is available.

Even in patients in whom therapeutic anticoagulation for treatment of SVT is contraindicated, prophylactic low molecular weight heparin (LMWH) is nevertheless recommended postoperatively for at least 7 to 10 days to reduce postoperative venous thromboembolism (VTE). Once there is no longer a contraindication to therapeutic anticoagulation, therapeutic LMWH or unfractionated heparin (UFH) should be started or resumed, to reduce VTE complications.

2012 年美国胸科医师学会 (ACCP) 的 VTE 疾病抗血栓形成治疗指南建议采用预防性剂量或中等剂量的低分子量肝素 (LMWH)、预防性剂量的磺达肝素或中等剂量的普通肝素 (UFH) 治疗至少 45 天。[57]Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis. 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(suppl 2):e419S-94S.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278049/http://www.ncbi.nlm.nih.gov/pubmed/22315268?tool=bestpractice.com证据 null症状改善：在关于 3,002 例浅静脉血栓性静脉炎 (SVT) 且无伴随 DVT 或 PE 患者的一项试验中，有高质量的证据表明，与安慰剂相比，采用每日 2.5 mg 磺达肝素进行为期 45 天治疗对急性 SVT 患者有效（相对风险降低 85%，95% 置信区间：74-92）。[53]Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010;363:1222-1232.http://www.nejm.org/doi/full/10.1056/NEJMoa0912072#t=articleTophttp://www.ncbi.nlm.nih.gov/pubmed/20860504?tool=bestpractice.com 主要结局包括死亡、症状性 PE、症状性 DVT 或症状性延伸至隐股静脉瓣连接处，或在第 47 天出现 SVT 症状性复发。两组之间没有出血相关差异。 该指南的 2016 更新版已经发布，然而其未涵盖 SVT。[58]Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315-352.http://www.ncbi.nlm.nih.gov/pubmed/26867832?tool=bestpractice.com 中间剂量大于预防剂量，小于治疗剂量。

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]University of Washington School of Medicine. Recommendations for management of superficial vein thrombosis. April 2015. https://depts.washington.edu/ (last accessed 4 November 2016).https://depts.washington.edu/anticoag/home/sites/default/files/Management%20of%20Superficial%20Vein%20Thrombosis.pdf

华法林可以替代普通肝素或低分子肝素，它可以与普通肝素或低分子肝素重叠使用4天，然后持续治疗至45天。与安慰剂相比，低分子肝素和磺达肝素已被证明可以减少SVT扩展和复发的风险，同时能有效控制局部症状。[4]Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2018 Feb 25;(2):CD004982.http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD004982.pub6/fullhttp://www.ncbi.nlm.nih.gov/pubmed/29478266?tool=bestpractice.com The quality of the evidence for comparison of fondaparinux with LMWH is low because there is no direct comparison in patients with SVT.[53]Decousus H, Prandoni P, Mismetti P, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010;363:1222-1232.http://www.nejm.org/doi/full/10.1056/NEJMoa0912072#t=articleTophttp://www.ncbi.nlm.nih.gov/pubmed/20860504?tool=bestpractice.com

The newer anticoagulants (dabigatran, rivaroxaban, edoxaban, and apixaban) are considered suitable alternatives. However, clinical data on their use in the management of SVT are only available for rivaroxaban.[65]Werth S, Bauersachs R, Gerlach H, et al. Superficial vein thrombosis treated for 45 days with rivaroxaban versus fondaparinux: rationale and design of the SURPRISE trial. J Thromb Thrombolysis. 2016 Aug;42(2):197-204.http://www.ncbi.nlm.nih.gov/pubmed/26973347?tool=bestpractice.com As a result, support for their use in SVT is extrapolated from their use in the management of DVT, and they are used in a similar way to warfarin.

Dabigatran and edoxaban require lead-in therapy with a parenteral anticoagulant such as UFH or a LMWH for 5 to 10 days before starting therapy, whereas rivaroxaban and apixaban can be initiated as monotherapy with no need for lead-in therapy.

应咨询专科医生或根据当地治疗原则指导治疗剂量。

Compression stockings are usually prescribed for 10 to 14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings (class I to II: 15-23 mmHg) to help in the resolution of superficial vein thrombophlebitis (SVT), are recommended. They are put on in the morning before getting up and removed in the evening when going to bed. Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index (ABPI) is <0.8.

局部热敷和抬高患腿可能有助于缓解急性症状。

Where anticoagulation is contraindicated, ligation with or without thrombectomy may be indicated, where local expertise is available.

即使是有治疗性抗凝治疗禁忌的 SVT 患者，仍然建议在术后接受至少 7-10 天的预防性低分子量肝素 (LMWH)，以减少术后静脉性血栓栓塞 (VTE)。只要不再有治疗性抗凝治疗禁忌，则应开始或恢复使用治疗性 LMWH 或普通肝素来减少 VTE 并发症。

通常要求穿戴弹力袜 10-14 天。建议在急性期使用短的或长的拉伸弹性绷带来缓解疼痛，随后使用压力袜（I 类至 II 类：15-23 mmHg），以辅助治疗浅静脉血栓性静脉炎 (SVT)。应在早上起床前穿上，晚上睡觉时脱掉。

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index (ABPI) is <0.8.

局部热敷和抬高患腿可能有助于缓解急性症状。

针对经选择患者组全部患者的治疗推荐

口服非甾体抗炎药也是可选的抗凝血剂，尤其是长度短且远离隐股静脉连接处的浅静脉血栓性静脉炎 (SVT)。非甾体抗炎药可以减轻症状，并可能防止 SVT 扩展和复发。[54]Superficial Thrombophlebitis Treated by Enoxaparin Study Group. A pilot randomized double-blind comparison of a low-molecular-weight heparin, a nonsteroidal anti-inflammatory agent, and placebo in the treatment of superficial vein thrombosis. Arch Int Med. 2003;163:1657-1663.http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/215878http://www.ncbi.nlm.nih.gov/pubmed/12885680?tool=bestpractice.com[61]Rathbun SW, Aston CE, Whitsett TL. A randomized trial of dalteparin compared with ibuprofen for the treatment of superficial thrombophlebitis. J Thromb Haemost. 2012;10:833-839.http://www.ncbi.nlm.nih.gov/pubmed/22360152?tool=bestpractice.com 然而，没有足够的数据支持非甾体抗炎药能降低静脉血栓栓塞的发生率。

对于有 LMWH 或 UFH 禁忌证的患者，应考虑使用非甾体抗炎药。

伴有小分支静脉曲张的 SVT，其扩展和复发的风险很低，故非甾体抗炎药可能优于低分子肝素。

非甾体抗炎药治疗时间通常在 6-10 天。

建议在 7-10天 时复查多普勒超声检查，以评估 SVT 的扩展。

相对于其他非甾体抗炎药，布洛芬和双氯芬酸的胃肠道不良反应风险较低。

非甾体抗炎药不应该与全身性抗凝治疗同时使用或者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。

通常要求穿戴弹力袜 10-14 天。建议在急性期使用短的或长的拉伸弹性绷带来缓解疼痛，随后使用压力袜（I 类至 II 类：15-23 mmHg），以辅助治疗浅静脉血栓性静脉炎 (SVT)。应在早上起床前穿上，晚上睡觉时脱掉。

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index (ABPI) is <0.8.

局部热敷和抬高患腿可能有助于缓解急性症状。

It is feasible to treat less extensive superficial vein thrombophlebitis (SVT) with oral and/or topical NSAIDs. NSAIDs may also be favoured over low molecular weight heparin (LMWH) or fondaparinux in cases where the SVT involves small tributaries of varicose veins. This is because there is low risk of recurrence and extension in these veins compared with the saphenous veins.

The duration of NSAID treatment usually consists of a 6- to 10-day trial.

建议在 7-10 天时重复进行多普勒超声检查，以评估 SVT 的扩展和/或进展。

Selective cyclo-oxygenase 2 inhibitors (e.g., celecoxib) are not generally recommended because there may be an increased risk of thrombotic events compared with placebo and some NSAIDs.[66]Bing RJ, Lomnicka M.Why do cyclo-oxygenase-2 inhibitors cause cardiovascular events? J Am Coll Cardiol. 2002 Feb 6;39(3):521-2.https://www.sciencedirect.com/science/article/pii/S0735109701017491?via%3Dihubhttp://www.ncbi.nlm.nih.gov/pubmed/11823092?tool=bestpractice.com The thrombotic risk, however, is likely to be minimal when treating for a short period of time (6-12 days for SVT).

非甾体抗炎药不应该与全身性抗凝治疗同时使用或者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。

针对经选择患者组全部患者的治疗推荐

通常要求穿戴弹力袜 10-14 天。建议在急性期使用短的或长的拉伸弹性绷带来缓解疼痛，随后使用压力袜（I 类至 II 类：15-23 mmHg），以辅助治疗 SVT。在早上起床前穿上，晚上睡觉时脱掉。

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index (ABPI) is <0.8.

局部热敷和抬高患腿可能有助于缓解急性症状。

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。

有低质量的证据表明，局部外用类肝素等疗法可能有助于缓解插管引起的上肢 SVT 的急性症状。[56]Di Nisio M, Peinemann F, Porreca E, et al. Treatment for superficial infusion thrombophlebitis of the upper extremity. Cochrane Database Syst Rev. 2015;(11):CD011015.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011015.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26588711?tool=bestpractice.com

一项指南指出，在具有一个或多个 VTE 危险因素的患者中，采用 LMWH 或磺达肝素的预防性抗凝治疗可能有益处。[48]University of Washington School of Medicine. Recommendations for management of superficial vein thrombosis. April 2015. https://depts.washington.edu/ (last accessed 4 November 2016).https://depts.washington.edu/anticoag/home/sites/default/files/Management%20of%20Superficial%20Vein%20Thrombosis.pdf 在这些患者中，可以根据个体化的风险收益分析以及患者偏好进行决定疗法。

An alternative choice is treatment with NSAIDs. Selective cyclo-oxygenase 2 inhibitors (e.g., celecoxib) are not generally recommended because there may be an increased risk of thrombotic events compared with placebo and some NSAIDs.[66]Bing RJ, Lomnicka M.Why do cyclo-oxygenase-2 inhibitors cause cardiovascular events? J Am Coll Cardiol. 2002 Feb 6;39(3):521-2.https://www.sciencedirect.com/science/article/pii/S0735109701017491?via%3Dihubhttp://www.ncbi.nlm.nih.gov/pubmed/11823092?tool=bestpractice.com However, the thrombotic risk is likely to be minimal when treating for a short period of time (6-12 days for SVT). NSAIDs should not be given together with, or adjunctive to, systemic anticoagulation therapy as this combination may increase the risk of bleeding.

通常要求穿戴弹力袜 10-14 天。建议在急性期使用短的或长的拉伸弹性绷带来缓解疼痛，随后使用压力袜（I 类至 II 类：15-23 mmHg），以辅助治疗 SVT。在早上起床前穿上，晚上睡觉时脱掉。

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index (ABPI) is <0.8.

局部热敷和抬高患腿可能有助于缓解急性症状。

在广泛静脉曲张的部位反复发作 SVT 的情况下，推荐考虑静脉曲张手术，例如静脉曲张剥离或硬化疗法。

静脉曲张手术应该在急性 SVT 发作后进行，从而避免引起血栓栓塞并发症。

在手术治疗的同时，应考虑预防性使用低分子肝素治疗。