COMMENTARY

Association Between Superficial Vein Thrombosis and Deep Vein Thrombosis of the Lower Extremities

Graeme M. Lipper, MD

Disclosures

September 30, 2009

Association Between Superficial Vein Thrombosis and Deep Vein Thrombosis of the Lower Extremities

Binder B, Lackner HK, Salmhofer W, et al
Arch Dermatol. 2009;145:753-757

Study Summary

Superficial venous thrombosis (SVT), also termed superficial thrombophlebitis of the lower extremities is a common, generally benign condition characterized by tenderness, swelling, and induration occurring from thrombus formation within the superficial leg veins -- most commonly the great saphenous vein (60%-80% of cases) and small saphenous vein (10%-20% of cases).[1] Complications of SVT, such as pulmonary embolism, are extremely rare. However, according to one prevalence study, SVT may be associated with deep venous thrombosis (DVT) in up to 65% of cases. This suggests that the potential risk of thromboembolic complications stemming from SVTs may be underestimated.[2]

In an informative prospective analysis, Binder and colleagues set out to determine the incidence of lower extremity DVT in patients with ultrasonography-confirmed SVT. They studied 46 outpatients (32 women and 14 men; mean age, 65 years) with clinical signs of lower extremity SVT. In this sample, risk factors for SVT included age older than 60 years (29 of 46 cases) and female gender (70%). All patients underwent color-coded duplex sonography and compression ultrasonography of all venous segments (groin to ankle) of both lower limbs. In addition, laboratory studies were conducted including a D-dimer assay and complete work-up for thrombophilic disorders (ie, protein C, protein S, antithrombin III deficiency, factor V Leiden mutation, and antiphospholipid antibodies).

In Binder and colleagues' SVT cohort, ultrasonography revealed concomitant, mostly asymptomatic DVT in 11 of 46 patients (24%). Although most of these cases (73%) occurred in the same leg as the SVT, 9% occurred in the contralateral leg, and 18% occurred in both legs. Five DVTs occurred in the ipsilateral leg through progression of the SVT into the deep venous system via perforating veins. D-dimer levels were elevated in 37 of 46 patients, and 8 patients had heterozygous mutations of factor V Leiden. The strongest risk factors for the development of DVT were SVT of the lower leg and increased D-dimer levels. In agreement with prior studies, additional DVT risk factors included age older than 60 years, female gender, and the presence of malignancy.[1,3] In contrast, SVTs located in the thigh region and the finding of normal D-dimer levels reduced the likelihood of concomitant DVT.

Viewpoint

Primary risk factors for both SVT and DVT include the presence of varicose veins, a thrombophilic disorder (eg, factor V Leiden mutation), oral contraceptive use, immobilization, malignancy, trauma to the area, or history of thromboembolism.[1] In addition, much practical information can be gleaned from Binder and colleagues' recent analysis. As the investigators conclude:

  • SVT of the lower extremity may present a higher risk of associated DVT (24% in their cohort) than previously reported.[3,4] As in the current study, DVT is often asymptomatic.

  • Although most DVT associated with SVT occurs in the ipsilateral leg (most commonly through propagation of thrombus through perforating veins into the deep venous system), DVT may also occur in noncontiguous sites of the same leg or even in the contralateral leg. This is likely due to an associated thrombophilic state.

  • In cases of SVT, elevated D-dimer levels predict a higher likelihood of concomitant DVT.[5] Conversely, normal D-dimer levels reduce the risk of concomitant DVT.

On the basis of these observations, Binder and colleagues reasonably conclude that patients with SVT, especially of the lower leg, should be evaluated for the possibility of concomitant DVT; this should be done using ultrasonography to inspect the deep venous networks of both legs, from groin to ankle. Assessment of both legs is especially crucial in patients with SVT and elevated D-dimer levels because such individuals are at high risk of developing concurrent DVT.

Abstract

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