Monday, March 4, 2024

What is Venous thrombosis? How to prevent and treat this disease

Phlebitis is inflammation of the walls of the veins of the superficial venous system. This inflammation can occur both with and without thrombi.

It is a term that has been used as a synonym for thrombophlebitis, phlebothrombosis, varicophlebitis. “but it leads to confusion, which is why for a few years, doctors have preferred to speak of venous thrombosis, which is the formation of a blood clot in inside the vein.”

varicophlebitis must also be distinguished: a more specific term, the inflammation of the veins in a previous varicose vein.

Thrombophlebitis is caused by the complication of a superficial venous system that is damaged or has varicose veins. And that produces inflammation of the endothelium -the internal part of the vein- with the formation of thrombi.

Difference Between Phlebitis and Thrombophlebitis

Phlebitis is caused by inflammation of the vein wall. Likewise, thrombophlebitis is the same process but with the presence of a thrombus. “The clinical difference is that when you have phlebitis, the part of the inflamed vein is red, hot and very painful, and when there is a thrombus, it is tough and very dilated.”

causes

80% of the blood circulates through the deep venous system. Those veins inside the muscles are not seen. Movement in the muscles causes these veins to compress and the blood to rise.

15-20% of blood goes through the simple system, which is what you see in which varicose veins occur. About this circuit, a system of valves inside the veins makes the blood go from the distal to the proximal parts and from the superficial to the deep system. “All the blood collected from the periphery of the lower limb goes through the superficial and enters the deep. And all the blood from the deep rises due to the contraction of the muscles and the pressure generated when walking on the sole”.

What happens when that system fails? “This generally happens because the valves fail, which causes the veins to dilate and the valves not close. This makes the blood go like an elevator: down and up. Thus, the veins dilate more and more, and the valves prevent the blood from going from the simple system to the deep system, passing from the deep system to the external system. When this happens, the veins dilate, and varicose veins appear”. 

In this context, three types of vein disease can occur:

  • Thromboembolic disease: Formation of thrombi in the deep venous system, which the appearance of pulmonary thromboembolism can complicate. 
  • Venous insufficiency: Its most common manifestation is the appearance of varicose veins.
  • Phlebitis: Inflammation with or without thrombi of the veins of the superficial venous system. 

The causes that produce venous thrombosis are often unknown. “Deep vein thrombosis can occur after surgical interventions, prolonged bed rest, infectious diseases, tumour. They are more frequent as we age. Superficial venous thromboses occur, in the majority, on previous varicose veins”. 

Phlebitis or irritative superficial venous thrombosis can occur in the arms and hands of people admitted due to droppers or when introducing medication into the veins of hospitalised people. 

Likewise, deep vein thrombosis can also appear. However, not very frequent after trips in which the same position has been maintained for several hours, as is the well-known economy class syndrome. 

Phlebitis and varicophlebitis are the most frequent complications of chronic venous insufficiency. These can also be triggered after a blow, insect bite, infection, or sclerotherapy treatment to make varicose veins disappear.

Symptoms

The symptoms that can alert to the presence of venous thrombosis are varied. 

In the case of deep thrombosis, there may not be any particular symptoms. But when they do, says Rial, it is usual for a sudden increase in the limb’s volume, a sensation of numbness, pain and inflammation. The only present symptom is the appearance of that inflammation in one of the extremities.

  • Tumefaction is the inflammation of the varicose vein and its surroundings. 
  • Cutaneous hypersensitivity to low-intensity stimuli, which means that it is painful to the touch.
  • There is no infectious component but only inflammatory.

In the case of venous insufficiency, and before varicose veins appear, it can be experienced in the legs:

  • Heaviness.
  • Fatigue.
  • Tingle.
  • Cramps.
  • Oedema (increased size) that improves with horizontal rest.

These symptoms tend to worsen when they spend a lot of time standing. And in fact, they are more frequent in those who usually stand for work-related reasons. “It often begins with the observation that at the end of the day, the mark of the sock is noticeable since little by minor oedema is produced and that over the years will cause varicose veins to appear.

Prevention

The most important measures to prevent venous disease are modifying lifestyles, performing physical exercise that favours venous return, and avoiding a sedentary lifestyle and prolonged rest. In the case of immobilised people due to an operation, it is also advisable to follow the doctor’s advice and administration heparin whenever indicated. 

Among other recommendations, the experts advise:

  • Physical exercise
  • Avoid standing for long periods, especially when it is boiling. 
  • Avoid sitting for a long time and if you have to, have your legs elevated. It is better to get up and move your muscles.
  • Sleep in articulated beds or in which the feet are elevated, so the ankles are above the thighs and the rest of the body.
  • Do not wear very tight clothing.
  • Special attention in pregnant women, in which the growth of the fetus produces a compression of the iliac veins.
  • Do not wear very flat shoes but with a small heel.
  • A balanced diet.

In patients who have had a thrombosis and it has resolved or who begin to have symptoms of venous insufficiency, the use of compression stockings is recommended. Therefore, it is recommended, “in people who have to stand for a long time or in jobs that take place in scorching places -as is the case with bakers or waiters- especially in summer to prevent venous insufficiency”. 

In patients who have already had a thrombosis, we must insist a lot on all prevention and control measures: 

  • Control the weight with the help of the BMI and assess how it evolves to reduce, especially the abdominal perimeter.
  • Recommend physical exercise at least three times a week for 45 minutes at a good pace. 
  • Elevation of the lower limbs when lying down.
  • Avoid nearby heat sources.
  • Compression treatment with elastic compression stockings. 
  • Pharmacological therapy with venotonics.

Types

Venous thrombosis can be classified according to the areas in which they occur. Two types:

  • Deep vein thrombosis: They can occur after surgical interventions, prolonged bed rest, infectious diseases, and tumours.
  • Superficial venous thrombosis: They usually occur on previous varicose veins. Phlebitis, thrombophlebitic and varicophlebitis will be included here. They are more common in women since it is in this sex where there is a greater frequency of varicose veins.

There does not seem to be a difference between men and women in the number of deep vein thromboses. However, Rial recalls, “pregnant women and in those who take contraceptives, there is more risk than in the same age group in men.” 

Diagnosis

The diagnosis of venous thrombosis, venous insufficiency and phlebitis must be made by a doctor and needs to be confirmed with an Echo Doppler, which allows the superficial and deep veins to be observed. 

Treatments

The treatment of venous thrombosis should always include the use of compression stockings to promote venous return. 

In the case of varicophlebitis, patients are usually prescribed anti-inflammatory drugs every 6-8 hours or paracetamol if they do not tolerate it. “You must add a compressive bandage and rest with your legs up.”

Superficial venous thrombosis should be treated with heparin between 30 and 45 days. “If it has occurred on a varicose vein, it should be evaluated for surgical intervention since the probability of recurrence is high.” 

In the case of deep vein thrombosis, “treatment with heparin is usually started in subcutaneous injections. Subsequently, he is switched to oral anticoagulants . The duration of anticoagulation is variable”. For this reason, in a first thrombosis, anticoagulation is administered for between 3 and 6 months, but depending on the cause, “it can be prolonged longer. If they are recurrent deep vein thrombosis or there are genetic factors, sometimes anticoagulation has to be maintained indefinitely”.

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