Superficial thrombophlebitis of the cephalic vein-A 52-Year-Old Woman with Right Arm Swelling and Redness

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 Superficial thrombophlebitis of the cephalic vein

1. Cause and Etiology

Superficial thrombophlebitis (STP) of the cephalic vein occurs when there is inflammation and thrombus (blood clot) formation within the cephalic vein, a superficial vein located along the lateral (thumb) side of the upper limb.

Common causes and risk factors include:

  • Venous cannulation or intravenous (IV) lines: Insertion of catheters into the cephalic vein is a major precipitating event.
  • Trauma or irritation: Mechanical injury during venipuncture, blood draws, or trauma.
  • Hypercoagulable states: Inherited thrombophilias (e.g., Factor V Leiden mutation, protein C/S deficiency), malignancy, pregnancy, or estrogen therapy.
  • Infection: Local or systemic infections can promote endothelial damage and thrombosis.
  • Inflammatory diseases, Such as Behçet’s disease or Buerger’s disease.
  • Prolonged immobilization: Less common for superficial veins, but still possible.
  • Varicose veins: More relevant in the lower limbs, but superficial venous disease predisposes to thrombophlebitis in general.

2. Pathophysiology

The underlying process follows Virchow’s triad:

  • Endothelial injury: Trauma from IV lines or blood draws causes endothelial disruption, promoting clot formation.
  • Venous stasis: Immobility or compression around the vein slows blood flow.
  • Hypercoagulability: Systemic or local prothrombotic conditions enhance clotting.

When these factors converge:

  • Endothelial cells activate platelets and the coagulation cascade.
  • A thrombus forms within the vein lumen.
  • Inflammatory cells (neutrophils, macrophages) infiltrate the vessel wall.
  • Vein becomes inflamed, thickened, tender, and often cord-like.

Secondary infection (septic thrombophlebitis) can complicate the condition, especially if IV lines were involved.

3. Epidemiology

  • Age: More common in adults, especially middle-aged and elderly.
  • Gender: Slight female predominance (possibly related to hormone use and varicosities).
  • Incidence: Exact rates for cephalic vein-specific thrombophlebitis are unclear, but STP in general is a relatively frequent vascular condition, especially in hospitalized patients with IV catheters.
  • Risk settings: Hospitalization, IV drug use, cancer, and autoimmune diseases.

4. Clinical Presentation

Patients typically present with:

  • Localized pain over the cephalic vein in the forearm or upper arm.
  • Erythema and swelling along the course of the vein.
  • Palpable cord: A firm, tender vein can often be felt under the skin.
  • Warmth over the area.
  • Minimal systemic symptoms: Fever is rare unless infection complicates the thrombophlebitis.
  • Reduced range of motion: Particularly if the inflammation is extensive.
  • No significant limb edema: Unlike deep vein thrombosis (DVT).

In cases with septic thrombophlebitis:

  • Fever, chills, and purulent drainage may be present.

5. Imaging Features

Ultrasound with Doppler is the imaging modality of choice:

  • Non-compressibility of the cephalic vein.
  • Intraluminal echogenic material consistent with thrombus.
  • Absence of normal venous flow on color Doppler.
  • Perivascular inflammatory changes: Soft tissue edema around the vein.
  • Wall thickening: Sometimes seen.
  • No extension into deep veins: Important to differentiate from DVT.

Rarely, MRI or CT may be used if there is concern about extension, mass effect, or infection.

6. Treatment

Most cases are self-limited and can be treated conservatively:

  • Local measures:
    • Warm compresses.
    • Limb elevation.
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation.
  • Anticoagulation:
    • Usually not required unless:
      • The thrombosis is near the deep venous system (e.g., at the axillary vein junction).
      • The thrombosis is extensive.
      • A patient has hypercoagulable risk factors.
    • If anticoagulation is used, low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) may be prescribed.
  • Antibiotics:
    • Only if septic thrombophlebitis is suspected (e.g., fever, purulence).
  • Surgical intervention:
    • Rarely needed.
    • Thrombectomy or vein ligation may be considered if there is extensive clot, progression despite treatment, or a septic focus.
  • Removal of offending IV line or catheter:
    • Essential if thrombophlebitis is related to cannulation.

7. Prognosis

  • Excellent prognosis in uncomplicated cases.
  • Symptoms typically resolve within 1–2 weeks.
  • Recurrence is rare if risk factors are addressed.
  • Complications are uncommon but may include:
    • Extension into deep veins (DVT).
    • Pulmonary embolism (extremely rare in isolated cephalic vein thrombosis).
    • Chronic venous insufficiency (rare).
    • Septicemia occurs if the infection spreads.

Follow-up is necessary if:

  • Symptoms worsen.
  • There are signs of DVT or systemic infection.
  • A patient has ongoing prothrombotic risk factors.
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Case study: A 52-Year-Old Woman with Right Arm Swelling and Redness 
Superficial Thrombophlebitis of the Cephalic Vein

History and Imaging

  1. A 52-year-old woman with a history of multiple malignancies, including oropharyngeal carcinoma, presented with swelling and redness of the right arm following a recent hospital discharge.

  2. Multiple images of the distal radial vein were obtained using B-mode, M-mode ultrasound, and color Doppler. Comparative images of the proximal axillary vein were also provided, including compression views.

Quiz:

  1. What is the most prominent abnormal finding?
    (1) Superficial thrombophlebitis of the axillary vein
    (2) Deep venous thrombosis
    (3) Superficial thrombophlebitis of the cephalic vein
    (4) Post-thrombotic syndrome

  2. What is the greatest risk factor for this condition?
    (1) Female sex
    (2) Male sex
    (3) Age under 60 years
    (4) Use of anticoagulation medication

  3. Which group has the highest risk of complications from this condition?
    (1) Males
    (2) Females
    (3) Individuals under 60 years old
    (4) Those taking anticoagulant medication

  4. Which vessel is most associated with a higher risk of complications in this condition?
    (1) Cephalic vein
    (2) Basilic vein
    (3) Greater saphenous vein
    (4) Radial vein

Findings and Diagnosis

Findings
Ultrasound examination revealed that the superficial branches of the distal right cephalic vein were dilated and heterogeneous, showing diminished and turbulent flow.

Differential Diagnosis

  • Deep vein thrombosis (DVT)

  • Post-thrombotic syndrome

  • Thrombophlebitis

  • Phlegmasia

  • Cellulitis

Diagnosis: Superficial thrombophlebitis of the cephalic vein

Discussion

Superficial Thrombophlebitis of the Cephalic Vein

Superficial thrombophlebitis is an inflammatory process associated with thrombus formation within a superficial vein. Traditionally, it has been considered a benign and self-limiting condition. Although there have been claims suggesting that superficial thrombophlebitis may be associated with deep vein thrombosis (DVT), this remains controversial.

Epidemiology
The incidence of superficial thrombophlebitis is not well studied but is thought to be higher than that of deep vein thrombosis, which occurs in approximately 1 in 1,000 people annually. It is more common in elderly patients and females; however, males are more likely to develop complications. Thrombosis involving the greater saphenous vein is most strongly associated with an increased risk of complications.

Clinical Presentation

  • Pain, redness, and swelling over the area of thrombosis

Imaging Features

  • Non-compressible vein

  • Presence of intraluminal thrombus in the affected vein

  • Reduced venous pulsatility

  • Lack of vein expansion during the Valsalva maneuver

  • Loss of Doppler flow signal

Treatment
The treatment of superficial thrombophlebitis primarily involves the use of anticoagulation. Although evidence is limited, fondaparinux has the strongest supporting data. The main goals of treatment are to relieve local symptoms and to prevent extension of the thrombus into the deep venous system. However, the overall quality of evidence is low due to limitations in study design.

References

(1)      Decousus H, Epinat M, Guillot K, Quenet S, Boissier C, Tardy B. Superficial vein thrombosis: Risk factors, diagnosis, and treatment. Curr Opin Pulm Med. 2003;9(5):393-397.

(2)      Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2018;2(2): CD004982. doi: 10.1002/14651858.CD004982.pub6.

(3)      Lutter K, Kerr T, Roedersheimer L, Lohr J, Sampson M, Cranley J. Superficial thrombophlebitis diagnosed by duplex scanning. Surgery. 1991;110(1):42-46.

(4)      Nasr H, Scriven J. Superficial thrombophlebitis (superficial venous thrombosis). BMJ. 2015;350:h2039. doi: 10.1136/bmj.h2039.

(5)      Ploton G, Pistorius MA, Raimbeau A, et al. A STROBE cohort study of 755 deep and superficial upper-extremity vein thrombosis. Medicine (Baltimore). 2020;99(6):e18996. doi: 10.1097/MD.0000000000018996.

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