home Audience 4 Thrombophlebitis and phlebothrombosis. Thrombosis and thrombophlebitis of the veins of the lower extremities: etiology, diagnosis and treatment. What is the difference between phlebothrombosis and thrombophlebitis

Thrombophlebitis and phlebothrombosis. Thrombosis and thrombophlebitis of the veins of the lower extremities: etiology, diagnosis and treatment. What is the difference between phlebothrombosis and thrombophlebitis

Phlebothrombosis- the formation of a thrombus in the lumen of the vein, fixed to the vein wall, completely or partially (“floating thrombus”) obstructing the vessel with the addition of inflammatory changes in the venous wall.

Thrombophlebitis called inflammatory changes in the venous wall, followed by the formation of a blood clot in the lumen of the vein.

Etiology and pathogenesis (Virchow triad 1856):

change in the inner wall of the vessel (injury to the vascular wall, violation of the integrity of the endothelium, exposure of the subendothelial layer)

changes in blood composition (deficiency of coagulation inhibitors, disturbance in the fibrinolysis system, increase in blood viscosity)

slowing blood flow (immobilization)

From the point of view of modern phlebology, there are no fundamental differences in the pathogenesis of thrombophlebitis and phlebothrombosis. With vein thrombosis, there are always inflammatory changes in the venous wall, and inflammation of the vein wall (phlebitis) is accompanied by its thrombosis. However, phlebologists, understanding the conventionality of such a division, use the term thrombophlebitis with damage to the subcutaneous, and phlebothrombosis - deep veins. The only exceptions are the extremely rare cases of purulent fusion of thrombotic masses today, which can occur both in the superficial and in the deep venous systems.

Classification:

By etiology:

infectious;

allergic;

aseptic.

According to the flow, they distinguish:

Acute thrombophlebitis (duration of the pathological process up to 1 month);

Subacute thrombophlebitis (duration of clinical manifestations from 1 to 2 months);

Chronic thrombophlebitis, or post-thrombophlebitic syndrome (a long-term pathological process in the venous system due to thrombophlebitis, which develops over 2-3 months).

By the nature of inflammation, thrombophlebitis is distinguished into:

Not purulent.

According to the localization of the pathological process, there are:

Thrombophlebitis of superficial veins;

Thrombophlebitis of deep veins.

Clinical picture:

Deep vein thrombophlebitis is an independent or complication of superficial thrombophlebitis. Most often, the deep veins of the lower leg are affected, then the popliteal and overlying veins of the thigh. Deep vein thrombosis is always severe in its consequences and potentially dangerous disease. Symptoms of damage to the veins of the lower leg: sudden onset, arching pains and seals along the deep veins, a local increase in body temperature. Puffiness develops, a feeling of fullness, bursting, heat and cramps in the calf muscles. Pain, heaviness, and the sensations just mentioned increase sharply when lowering the leg. The volume of the corresponding part of the limb increases. Can't stand up. The skin on the foot, fingers, lower leg becomes slightly shiny due to swelling and pale. The pattern of cutaneous and saphenous veins sharply increases, sometimes they noticeably expand.

Damage to the popliteal and especially the femoral vein proceeds much more severely than thrombophlebitis of the leg. Swelling of the leg develops rapidly. The skin becomes hot, cyanotic. Vasospasm develops, which is determined by the state of the pulse and changes in skin temperature. Severe pains appear along the affected veins of the lower leg and thigh. Swelling and limited movement in the knee joint. The tissues are tense along the thrombosed vein, the skin is hot to the touch, edematous. There is a sharp pain along the neurovascular bundle. Subcutaneous veins are dilated and clearly visible against the background of cyanotic and slightly reddened skin.

With the pelvic-femoral form of thrombophlebitis, i.e., when the iliac veins, the inferior vena cava are involved in the process, especially severe pains are localized in the lower leg, thigh and buttock, and the lower half of the abdominal wall. Violated bowel function, bladder. A severe general reaction of the body develops with high body temperature, leukocytosis, increased ESR, chills, etc. There is swelling of the leg, and sometimes the genitals, perineum, lower part of the anterior abdominal wall.

There are the following clinical options phlebothrombosis of deep veins.

White pain phlegmasia: the disease is accompanied by a sharp spasm of arterial vessels. Severe salt syndrome, the limb is pale, cold to the touch, peripheral vascular pulsation is absent or sharply weakened. It is difficult to differentiate from acute disorders of arterial circulation.

Blue pain phlegmasia- the most severe form of phlebothrombosis. Almost all venous vessels of the extremity are affected with a sharp violation of venous blood flow and the rapid development of gangrene of the extremity.

Diagnostics:

Radionuclide study with labeled fibrinogen (looks for a hidden source of thrombosis. Allows you to identify asymptomatic thrombosis in various pools).

Duplex scanning (two-dimensional image of blood vessels with the ability to assess the state of the vascular wall, the nature and speed of blood flow through them).

Ultrasonic angioscanning (allows you to assess the condition of the vein, surrounding tissues, determine the location of the thrombus, its extent and the nature of thrombosis).

Treatment

Conservative:

The use of elastic compression of the affected limb, the use of local hypothermia at the call of the projection of the vascular bundle, which helps to subside phlebitis and reduce pain.

Anticoagulant therapy (direct - heparin (about 7 days), indirect - antivitamin K (on the 3rd day)).

Surgical:

Endovascular operations (percutaneous implantation of wire cava filters. In a sleeve with a diameter of about 3 mm, they are installed through the left subclavian or right jugular vein distal to the mouths of the renal veins).

Plication of the inferior vena cava (suturing the lumen of the inferior vena cava below the mouths of the renal veins with a U-shaped suture so that the lumen of the vein is divided into a number of channels. About 5 mm in diameter, sufficient for outflow of venous blood, but not allowing large thromboemboli to pass through).

Ligation of the vein (prevents embolization of the pulmonary vascular bed. They ligate those veins that stop blood flow in which does not cause serious violations of the venous outflow).

Palliative thrombectomy (attempts to completely remove thrombotic masses from the venous bed).

Complications. Pulmonary embolism, myoglobinuria, hypovolemic shock, hyperkalemia, consumption coagulopathy. In the long term, postthrombophebitic syndrome develops.

Prevention. Elastic bandaging of the limb during and after surgery, childbirth, use of the veins of the lower extremities for infusion should be avoided. Early rising, therapeutic exercises after surgery.

There is no single view among physicians as to whether thrombophlebitis and phlebothrombosis should be considered as different pathologies or whether they should be considered one disease. As for clinical practice, three names are used here to denote damage to the venous system by blood clots: “venous thrombosis” (with indication of localization), “phlebothrombosis” and “thrombophlebitis”.

With regard to venous thrombosis, there is no disagreement among physicians - this term is used as a designation for the entire group of diseases associated with blood clots. But there is confusion about the other two names: some experts consider the names synonymous, others - different pathologies that have fundamental differences.

Differences between diseases

More recently, it was believed that with thrombophlebitis, pathology first covers the venous wall and only then does a thrombus form. Moreover, the thrombus is tightly fixed on the wall, and therefore the probability of its separation with subsequent embolization is practically reduced to zero. Such a view of the problem was axiomatic - based on this, therapeutic tactics were built.

Phlebothrombosis was considered as a process in which a thrombus occurs without prior changes in the venous wall. It was this fact that explained the almost unsystematic course of phlebothrombosis in most cases. Unlike thrombophlebitis, in the case of phlebothrombosis, there is a high probability of a thrombus breaking off, since the blood clot is less reliably fixed to the venous wall.

The above ideas about thrombophlebitis and phlebothrombosis have dominated for many years - they have developed back in those days when operations on thrombosed veins were quite rare. However, as surgeons gained experience, the old views turned out to be untenable from an evidence point of view: it turned out that there are no fundamental differences between the pathogenesis of both pathologies considered in this article.

The inflammatory process in the venous wall (most often aseptic) leads to the formation of blood clots, and the occurrence of a thrombus is associated with an endothelial reaction and phlebitis.

Thus, both processes (phlebitis and thrombosis) are interrelated, and arguments about which of these pathologies is primary resemble a dispute about the primacy of an egg or a chicken.

With sufficiently limited symptoms of phlebothrombosis during surgery, pronounced phlebitis and inflammatory changes in paravasal tissues are found at the site of primary thrombus formation. With typical thrombophlebitis, when the inflammatory process is obvious, the proximal part of the thrombus can be located completely freely in the vascular lumen, and the manifestations of phlebitis will become apparent only after a few days.

Thus, based on classical concepts, in the same patient, both thrombophlebitis and phlebothrombosis can be noted at the same time in different parts of the venous system.

Most phlebologists are currently aware of the conventionality of separation, in which phlebothrombosis and thrombophlebitis are considered different diseases. Therefore, experts use the term "thrombophlebitis" when they talk about damage to the saphenous veins, and by "phlebothrombosis" they mean pathology in the deep veins. In the case of phlebothrombosis, the symptoms are almost imperceptible, since the vein is located at a depth - in the fascial case, and the manifestations of the disease can only be judged by violations of the outflow from the veins (swelling, pain syndrome). It should be noted that macroscopic and microscopic transformations in the vein wall caused by the inflammatory process are present both in the case of deep vein thrombosis and in the case of thrombophlebitis. The only exception is the currently very rare purulent fusion of blood clots, which can occur both in superficial veins and in deep ones.

From the point of view of the clinical approach, acute thrombophlebitis is especially dangerous, since if a thrombus is localized in the saphenous veins, it can go into the deep veins of the legs with a high probability of serious complications. Among the consequences of such a development of events are chronic venous insufficiency, trophic ulcers, myocardial infarction and even death.

At the present stage, many doctors associate thrombophlebitis with varicose veins. This opinion is especially common if the patient has symptoms corresponding to varicose veins - venous nodes with pronounced varicose changes.

Among general practitioners, there is such a view on phlebothrombosis and thrombophlebitis: the latter, unlike deep vein damage, is not a serious pathology. This approach is due to what was said above - the perception of the two names as different pathological processes, although in practice it has been proven that this is not the case.

The formation of blood clots in the saphenous veins may well be combined with a similar pathology in the deep veins. This possibility exists due to the spread of the process through fistulas, perforating veins, and also due to the simultaneous formation of a thrombus. According to statistics, 10-15% of patients with thrombophlebitis have blood clots in deep veins.

In most cases, the spread of thrombosis to deep veins can be avoided. However, if time is lost, pathology transforms into a completely different format. Even if no pulmonary embolism occurs, phlebothrombosis will require complex, lengthy treatment (often lifelong).

Features of the development and treatment of phlebothrombosis

Phlebothrombosis (deep vein thrombosis) is a pathological process in which blood clots form in the bloodstream, which are fixed on the veins.

Most often, the disease is associated with an increase in blood density and impaired blood flow, which leads to thrombosis. The thrombus is fixed on the venous wall. Moreover, in the first 5-7 days, the blood clot is held very unreliably, which creates an increased risk of its separation with the possibility of pulmonary embolism.

Causes of the disease

The causes of phlebothrombosis can be divided into three groups (the so-called Virchow triad):

Damage to the venous wall (without rupture). In this case, the body connects a mechanism that inhibits bleeding. As a result, the volume of platelets increases sharply, and prostacyclin (does not allow platelets to connect to each other), on the contrary, becomes smaller. Thrombi are easily formed in the altered blood composition.

Blood clotting disorder (thrombophilia). It is also possible to reduce the activity of factors that counteract coagulation (hypercoagulation). The pathological process can be triggered both under the influence of external factors and as a result of failures in the body itself (for example, in the case of an excess of adrenaline).
Violation of the nature of the blood flow. Too slow blood flow, as well as turbulent, provokes the formation of blood clots.

For the development of thrombosis, any of the above reasons is sufficient. All other causes are secondary, but may have additional predisposing significance. Among the secondary causes of thrombosis are the following:

genetic predisposition;
autoimmune diseases;
oncological diseases;
a long period of immobilization (bed rest, sedentary work, constant flights in an uncomfortable position);
injuries (surgical interventions, bruises, fractures);
bad habits (drugs, alcohol, tobacco).

Symptoms

Symptoms of phlebothrombosis are most often mild. This is due to the fact that the vessels located deep in the lower extremities are affected.

To detect the disease, a system of tests is used:

Homans symptom. With this test, you can assess the patency of deep veins in the lower leg. For examination, the patient lies on his back, bends his knees and then bends the ankle to the back. If there is pain in the calf muscle, the symptom test is positive.

Payr's sign. For the test, palpation of the back of the ankle is performed. Pain on palpation indicates a positive test result.
Lowenberg's sign. A cuff of a special device, a sphygmomanometer, is applied to the lower leg. Next, air is injected into the cuff to a level of 60-150 millimeters of mercury. If pain occurs, the symptom test is positive.
Symptom Pratt. A positive result on the symptom is noted in the case of a pronounced venous network on the lower limb.
Symptom of Sperling. The test is positive if the skin is pale with a bluish tint.

There are a number of additional secondary signs of phlebothrombosis:

increased fatigue;
heart rhythm disturbances, tachycardia;
increase in body temperature up to 39-40 degrees;

increased local temperature in certain areas of the lower extremities;
pulling, arching pain sensations (usually become more intense in the vertical position of the body).

Classification

Deep vein thrombosis is classified according to a number of criteria (localization, degree of development, types of thrombus). In turn, such a parameter as localization is also heterogeneous and has its own classification:

phlebothrombosis in the vessels associated with the inferior vena cava (ileofemoral, muscular veins of the leg, kavaileofemoral, trunk of the inferior vena cava);
phlebothrombosis in vessels associated with the superior vena cava (vein trunk, innominate veins, orifices of unpaired veins, complete thrombosis of the upper limb).

With all this, most often, according to localization, phlebothrombosis is divided into 4 groups:

deep veins of the leg;
popliteal vein;
femoral;
iliac-femoral.

According to the degree of development, the disease is divided into three types:

acute thrombosis (development period - up to 2 weeks);
subacute (from 2 weeks to 2 months);
chronic (over 2 months).

According to the type of thrombus, there is the following classification:

occlusive thrombi (stretched along the vein);
non-occlusive thrombi (parietal);
floating (attached to the vein only by a small area, and therefore can always come off);
embologenic (mobile).

Deep vein thrombosis can lead to dangerous complications, including:

post-thrombotic syndrome and chronic venous insufficiency;
trophic ulcers;

pulmonary embolism (can lead to a heart attack or even death).

Diagnostics

Diagnostic measures begin with an examination of the patient and the collection of anamnesis. Next, the doctor prescribes a set of laboratory and instrumental studies:

TEG - determination of the level of blood clotting using graphics;
APTT (activated partial thromboplastin time) - study of the internal and general pathway of blood coagulation;
thrombin production test;
general blood analysis;
ultrasonic techniques (coloring elements can be used);
venography (to assess the condition of the venous network and find a blood clot);

magnetic resonance imaging (allows you to examine deep veins);
radioisotope scintigraphy.

Timely and accurate diagnosis allows you to effectively treat and avoid dangerous complications of the disease.

Treatment

Both conservative methods and surgery can be used to help the patient. The specific treatment tactics is determined by the doctor, based on the stage of development of the pathological process and the general condition of the patient.

In acute deep vein thrombosis, the patient may need hospitalization. This condition is accompanied by severe swelling, bursting pain syndrome, cyanosis of the skin and high body temperature.

In conservative therapy are used:

anticoagulants (needed to reduce blood density);
phlebotonic drugs (improve vascular tone, which allows you to optimize blood flow);
deaggregating agents (prevent platelets from sticking together);
anti-inflammatory drugs (usually non-steroidal drugs are used);
slimming (compression) knitwear or elastic bandages (especially important at the recovery stage after thrombosis treatment);
the location of the lower extremities in an elevated position (above the level of the heart);
diet low in cholesterol.

If conservative methods do not give the desired result, phlebothrombosis can be treated with surgical methods. Indications for surgical intervention include a high probability of pulmonary embolism, gangrene, and purulent course of the disease.

The following surgical techniques are used:

Excision of the affected vein. In the case of large veins, prosthetics can be performed. However, preference is given to shortening the vein (if possible).
Partial occlusion. This technique consists in reducing venous patency through the use of a special clamp. Occlusion is used to prevent pulmonary embolism.
Endovascular surgery. In this case, a coil is inserted into the vein through the catheter, which blocks the passage for large blood clots.

Prevention

Preventive measures are reduced to creating conditions under which the likelihood of congestion or high blood viscosity will be minimized.

Prevention includes:

organizing a healthy diet;
wearing tight underwear;
reasonable motor activity (walking, swimming, therapeutic exercises);
regular examinations by a phlebologist.

Venous pathologies pose a danger to the patient and require serious complex treatment. If you have even the most minor symptoms, you should consult a doctor.

Thrombophlebitis and thrombosis can be distinguished by the location of the affected area. The development of thrombophlebitis occurs on the veins that go directly under the skin, and thrombosis usually occurs on deep venous vessels.

With the development of thrombophlebitis, blood clots appear in deformed veins, and thrombosis can occur in any venous vessel that does not have any changes.

Thrombophlebitis and phlebothrombosis appear on the walls of deep veins. But the first can develop on the superficial vein, and the second appears only on the walls of the deep veins.

Thrombophlebitis appears with varicose veins, with damage to the venous wall, when there is a violation of the outflow of blood plasma from the limb, slowing down the circulation of blood flow. This forms a thrombus that closes the lumen in the vein.

Phlebothrombosis occurs on a non-inflamed, deep-lying venous canal, with the vein itself unchanged. A thrombus is formed on the wall of the vessel, which has a loose structure. It is easily torn off and can move with the blood flow, which leads to the development of thromboembolism. If the vein is varicose, then thrombophlebitis may appear along with phlebothrombosis. The first gives full symptoms of the lesion, and the second proceeds without any symptoms.

Usually, pathological changes in the venous channels begin to develop due to varicose veins themselves, damage to the inner walls of blood vessels due to various injuries, the development of infection, and many other reasons. All this slows down blood circulation in the venous channels, and stagnation leads to inflammatory processes. Blood clots appear, which quickly harden, forming blood clots. This leads to complete stagnation of blood, inflammation of the soft tissues of the legs or arms.

Unlike thrombophlebitis, thrombosis is considered more dangerous, since with it blood clots can develop due to the slightest damage to the vein. And phlebothrombosis with thrombophlebitis appear due to changes in the properties of the blood itself.

Thrombosis can develop in non-inflamed venous vessels, and the appearance of thrombophlebitis is almost always associated with varicose veins. With thrombosis, the symptoms of the disease are not as pronounced as it happens with the appearance of thrombophlebitis, which is much easier to identify, since it proceeds with noticeable inflammatory processes at the local and general levels.

Factors affecting the appearance of pathologies

The difference in the causes of the development of a particular disease in the veins of the limbs is small. With both types of ailments, blood clots form. Regardless of the location of any of the pathologies, the main causes of their appearance are:

the development of varicose ailments;
various vascular diseases;
injury to the walls of the vein;
pathology with a change in the composition of the blood, an increase in its coagulability;
slowdown and stagnation in the blood flow.

Usually, diseases of the endocrine system, various tumors, chronic diseases of the cardiovascular system, infections (both local and general) can lead to such human conditions. Lesions can appear due to blood diseases, allergies, and neurotrophic disorders. The vein can be damaged during an injection or during a long period of catheterization, pelvic and lower abdominal surgery. Often a large role in the appearance of ailments in the veins is played by local inflammation or a purulent process. Thrombosis or thrombophlebitis can be caused by a metabolic disorder, poor diet, smoking and drinking, and malfunctions in the hormonal system. In women, pregnancy, abortion, childbirth can affect the appearance of venous diseases.

Thrombophlebitis can occur due to deformation of the veins that occurs with excessive stress on the hip joints, for example, with prolonged standing on the legs, heavy physical exertion (weight lifting). But the same happens with the patient's low mobility, sedentary work, when there is stagnation of blood in the veins of the legs.

Symptoms of various lesions of the veins

Thrombosis differs from thrombophlebitis and phlebothrombosis and its signs. With the last two ailments, the patient develops pain at the site of the lesion on the limb. But it is not constant, although it can increase dramatically when walking, standing for a long time or lifting weights. After that, there may be swelling on the tissues, heaviness in the legs. The skin around the site affected by a thrombus turns blue, stretches strongly, gives off an unnatural luster. Tense and dilated veins can be seen 3-4 days after the formation of blood clots.

The temperature of the skin on the legs can increase by two degrees. In some patients, this causes a general rise in body temperature. The pulsation of the artery on the sore leg may be weakened or absent altogether.

If thrombosis of deep veins or gastrocnemius vessels begins, then the symptoms are usually erased, since in most cases a sign of the disease is a small swelling in the ankle joint area and slight soreness in the calves during physical exertion.

Acute thrombophlebitis on the superficial veins gives pain of a pulling nature, which is localized at the site of development of the thrombus itself. The diseased vein thickens and begins to protrude above the surface of the skin. At the same time, the pulsation in the arteries of the leg does not disappear, as happens with thrombosis. It is difficult for the patient to move the leg, swelling is fixed on the limb. Swelling appears along the affected vein. Noticeable hyperemia on the soft tissues, infiltration. The skin at the location of the thrombus turns blue. With varicose veins, it is very tense. During the palpation of the affected area, the patient feels severe pain.

Thrombophlebitis is accompanied by the following signs of inflammation: the patient begins to feel sharply worse, he complains of general weakness, pain in the head, he is tormented by chills. Perhaps a significant increase in temperature - up to 38-40ºС.

With the development of thrombophlebitis in deep veins, uniform edema is observed on the lower leg and foot. The pain is dull. It can sharply increase when you press on the calves or the fold of the foot. It is difficult for the patient to walk, and in some periods of time the pain intensifies so much that the person cannot step on the foot.

If at least one of the above symptoms occurs, you should seek help from a doctor of the appropriate specialty (phlebologist).

The patient will undergo a medical examination and, in the presence of any of the described vein diseases, will begin to treat the disease. It is better not to self-medicate because of possible complications.

Many patients think that there is no difference between phlebothrombosis and thrombophlebitis, considering them synonymous with one pathology. In fact, these are completely different diseases, although they have a similar etiology. The differences between these two pathologies are noticeable upon closer examination.

Description of diseases

The main distinguishing feature of phlebothrombosis and thrombophlebitis is the location of the pathology. Thrombophlebitis is localized in the superficial vein, and phlebothrombosis affects the deep venous vessels. Another difference is in the condition of the veins. With thrombophlebitis, blockage occurs only in damaged vessels, while phlebothrombosis affects healthy vessels.

Vein pathologies can develop due to varicose veins, mechanical damage, infection, and other factors. In any case, there is a slowdown in blood flow through the vessels, which causes their inflammation and the formation of clots (thrombi).

It is phlebothrombosis that is the most dangerous vascular pathology, since the formation of blood clots occurs due to changes in the coagulation properties of the blood, and not as a result of their damage, as occurs with thrombophlebitis.

The difference between phlebothrombosis and thrombophlebitis is that in the first pathology, the violation manifests itself in a healthy vein. And this means that the symptoms are weak or completely absent.

Reasons for development

The etiology of these two diseases is the same. The formation of a thrombus occurs as a result of many factors and in most cases develops against the background of disorders:

Phlebeurysm;
Pathology of blood flow through the veins;
Injury to the walls of blood vessels;
Deviation from the norm of blood composition;
Decreased blood flow.

Such changes in the blood vessels can be caused by a number of reasons that affect the body. These include:

Violations of the endocrine system;
Active growth of malignant neoplasms;
Chronic form of vascular diseases;
Infectious processes in the body;
Violations of the composition of the blood;
Errors in the injection, suggesting injury to the vein;
Disorders of the nervous system;
Frequent location of the catheter in the same area;
Surgical intervention affecting the pelvis and abdominal cavity;
Pregnancy and childbirth;
artificial termination of pregnancy;
Violation of the hormonal background;
Improper nutrition or strict diets;
Bad habits;
Metabolism disorder.

Thrombophlebitis affects those vessels that have the greatest load. Therefore, most often this disease affects the lower limbs, which account for the entire load of the body, especially if a person is constantly in motion or lifts weights.

Not only an overabundance, but also a lack of movement causes the development of thrombosis. Moderate exercise is the best solution.

Signs and symptoms

The main symptom of phlebothrombosis is acute pain in the limb where the pathological process began. At the same time, it is not permanent, but manifests itself, first of all, while walking, carrying heavy loads and other situations when the legs have the greatest load.

Also, this condition is characterized by swelling of the soft tissues, which is accompanied by a feeling of heaviness and fullness in the legs. The skin around the affected area stretches and becomes bluish. Expansion and blockage of the vein becomes noticeable only a few days after the formation of a blood clot.

The temperature of the affected leg is usually 2 0 higher than the general body temperature. The pulsation of the artery in the injured leg may remain unchanged, but most often it is reduced or completely invisible.

If a person suffers from thrombophlebitis, the clinical picture of deep vein damage will be practically erased. In this case, the only manifestation may be a large swelling at the location of the ankle joint, as well as minor pain in the calf muscle.

The acute form of thrombophlebitis manifests itself as a pulling pain that occurs in the area of the affected vein. The vessel itself has a seal and can protrude above the skin. Unlike phlebothrombosis, with this pathology, the pulsation in the vein will be palpable and be normal.

Signs of thrombophlebitis may be accompanied by symptoms of an inflammatory process in the affected limb. Which include:

General disturbance of well-being;
Chills;
Headache;
Increased body temperature;
Weakness.

With the development of thrombophlebitis, there is a uniform development of swelling of the lower leg and foot. Pain sensations are dull in nature, which are aggravated by bending the leg or pressing on the affected area.

There are a lot of differences between these two diseases, however, if there is the slightest suspicion or a similar symptom, you should consult a doctor for a diagnosis.

Treatment

When diagnosing phlebothrombosis, complex treatment is prescribed. Conservative methods include medication and special procedures. Namely:

Taking anticoagulants normalize blood viscosity.
Disaggregants minimize the creation of clots and the formation of blood clots.
Phlebotonics improve blood flow and normalize vascular tone.
Immobilization helps to keep the affected limb in one position.
Compression with elastic bandages is necessary during the recovery phase.
A diet containing a minimum amount of cholesterol.

Depending on the severity of the development of the disease, surgical treatment may be prescribed. It consists in excising a vein and removing its damaged area.

In the case of diagnosing thrombophlebitis, complex therapy is also prescribed, which consists in the following procedures and preparations:

Fixation of the injured limb with a Beller splint.
Compression clothing, as well as fixation of the foot with elastic bandages.
Anticoagulant drugs.
Anti-inflammatory drugs.
A small amount of glucocorticoids.

Thrombophlebitis and phlebothrombosis are treatable. Its favorable outcome is most likely with the timely detection of pathology. And attention to your health plays an important role in this case.

What is the difference between phlebothrombosis and thrombophlebitis?

Differences between diseases

The inflammatory process in the venous wall (most often aseptic) leads to the formation of blood clots, and the occurrence of a thrombus is associated with an endothelial reaction and phlebitis.

Thus, both processes (phlebitis and thrombosis) are interrelated, and arguments about which of these pathologies is primary resemble a dispute about the primacy of an egg or a chicken.

Thus, based on classical concepts, in the same patient, both thrombophlebitis and phlebothrombosis can be noted at the same time in different parts of the venous system.

The formation of blood clots in the saphenous veins may well be combined with a similar pathology in the deep veins. This possibility exists due to the spread of the process through fistulas, perforating veins, and also due to the simultaneous formation of a thrombus. According to statistics, % of patients with thrombophlebitis have blood clots in deep veins.

Features of the development and treatment of phlebothrombosis

Phlebothrombosis (deep vein thrombosis) is a pathological process in which blood clots form in the bloodstream, which are fixed on the veins.

Causes of the disease

The causes of phlebothrombosis can be divided into three groups (the so-called Virchow triad):

Damage to the venous wall (without rupture). In this case, the body connects a mechanism that inhibits bleeding. As a result, the volume of platelets increases sharply, and prostacyclin (does not allow platelets to connect to each other), on the contrary, becomes smaller. Thrombi are easily formed in the altered blood composition.

Blood clotting disorder (thrombophilia). It is also possible to reduce the activity of factors that counteract coagulation (hypercoagulation). The pathological process can be triggered both under the influence of external factors and as a result of failures in the body itself (for example, in the case of an excess of adrenaline).
Violation of the nature of the blood flow. Too slow blood flow, as well as turbulent, provokes the formation of blood clots.

For the development of thrombosis, any of the above reasons is sufficient. All other causes are secondary, but may have additional predisposing significance. Among the secondary causes of thrombosis are the following:

genetic predisposition;
autoimmune diseases;
oncological diseases;
a long period of immobilization (bed rest, sedentary work, constant flights in an uncomfortable position);
injuries (surgical interventions, bruises, fractures);
bad habits (drugs, alcohol, tobacco).

Symptoms

Symptoms of phlebothrombosis are most often mild. This is due to the fact that the vessels located deep in the lower extremities are affected.

To detect the disease, a system of tests is used:

Homans symptom. With this test, you can assess the patency of deep veins in the lower leg. For examination, the patient lies on his back, bends his knees and then bends the ankle to the back. If there is pain in the calf muscle, the symptom test is positive.

Payr's sign. For the test, palpation of the back of the ankle is performed. Pain on palpation indicates a positive test result.
Lowenberg's sign. A cuff of a special device, a sphygmomanometer, is applied to the lower leg. The cuff is then inflated to millimeters of mercury. If pain occurs, the symptom test is positive.
Symptom Pratt. A positive result on the symptom is noted in the case of a pronounced venous network on the lower limb.
Symptom of Sperling. The test is positive if the skin is pale with a bluish tint.

There are a number of additional secondary signs of phlebothrombosis:

increased fatigue;
heart rhythm disturbances, tachycardia;
increase in body temperature up to degrees;

increased local temperature in certain areas of the lower extremities;
pulling, arching pain sensations (usually become more intense in the vertical position of the body).

Classification

phlebothrombosis in the vessels associated with the inferior vena cava (ileofemoral, muscular veins of the leg, kavaileofemoral, trunk of the inferior vena cava);
phlebothrombosis in vessels associated with the superior vena cava (vein trunk, innominate veins, orifices of unpaired veins, complete thrombosis of the upper limb).

With all this, most often, according to localization, phlebothrombosis is divided into 4 groups:

According to the degree of development, the disease is divided into three types:

acute thrombosis (development period - up to 2 weeks);
subacute (from 2 weeks to 2 months);
chronic (over 2 months).

According to the type of thrombus, there is the following classification:

occlusive thrombi (stretched along the vein);
non-occlusive thrombi (parietal);
floating (attached to the vein only by a small area, and therefore can always come off);
embologenic (mobile).

Deep vein thrombosis can lead to dangerous complications, including:

post-thrombotic syndrome and chronic venous insufficiency;
trophic ulcers;

pulmonary embolism (can lead to a heart attack or even death).

Diagnostics

Diagnostic measures begin with an examination of the patient and the collection of anamnesis. Next, the doctor prescribes a set of laboratory and instrumental studies:

TEG - determination of the level of blood clotting using graphics;
APTT (activated partial thromboplastin time) - study of the internal and general pathway of blood coagulation;
thrombin production test;
general blood analysis;
ultrasonic techniques (coloring elements can be used);
venography (to assess the condition of the venous network and find a blood clot);

magnetic resonance imaging (allows you to examine deep veins);
radioisotope scintigraphy.

Timely and accurate diagnosis allows you to effectively treat and avoid dangerous complications of the disease.

Treatment

In acute deep vein thrombosis, the patient may need hospitalization. This condition is accompanied by severe swelling, bursting pain syndrome, cyanosis of the skin and high body temperature.

In conservative therapy are used:

anticoagulants (needed to reduce blood density);
phlebotonic drugs (improve vascular tone, which allows you to optimize blood flow);
deaggregating agents (prevent platelets from sticking together);
anti-inflammatory drugs (usually non-steroidal drugs are used);
slimming (compression) knitwear or elastic bandages (especially important at the recovery stage after thrombosis treatment);
the location of the lower extremities in an elevated position (above the level of the heart);
diet low in cholesterol.

The following surgical techniques are used:

Excision of the affected vein. In the case of large veins, prosthetics can be performed. However, preference is given to shortening the vein (if possible).
Partial occlusion. This technique consists in reducing venous patency through the use of a special clamp. Occlusion is used to prevent pulmonary embolism.
Endovascular surgery. In this case, a coil is inserted into the vein through the catheter, which blocks the passage for large blood clots.

Prevention

Preventive measures are reduced to creating conditions under which the likelihood of congestion or high blood viscosity will be minimized.

organizing a healthy diet;
wearing tight underwear;
reasonable motor activity (walking, swimming, therapeutic exercises);
regular examinations by a phlebologist.

Venous pathologies pose a danger to the patient and require serious complex treatment. If you have even the most minor symptoms, you should consult a doctor.

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Deep vein thrombosis of the lower extremities (phlebothrombosis)

The pathological condition, manifested by the formation of blood clots with partial inflammation of the venous wall and impaired patency of the lumen of the vein, is called phlebothrombosis. In medical literature, everyday life and among specialists it is found under a different name - deep vein thrombosis of the lower extremities. No one will doubt the relevance of the topic due to the severity of the manifestations and the danger of complications of this disease. Women of reproductive age get sick more often. The young age group also predominates among men. It is important to consider the correct terminology in relation to this pathological condition. This is due to the fact that in most cases thrombosis is called thrombophlebitis, which is not entirely correct.

Phlebothrombosis and thrombophlebitis, what is the difference

It would seem that here to understand. But in fact, these are two completely different diseases. Common to them is only the pathogenetic basis, which is the formation of blood clots against the background of an inflamed venous wall. The difference lies in the fact that with thrombophlebitis, the process is localized in the superficial veins, and with phlebothrombosis, deep veins are affected. The clinical manifestations, complications and treatment of these conditions depend on this. Patient management is fundamentally different.

With thrombophlebitis, inflammatory changes prevail over the formation of blood clots. Deep vein thrombosis of the lower extremities is manifested by massive thrombus formation with minimal inflammatory changes in the venous wall.

Anatomical background

The venous system of the body is represented by superficial and deep venous plexuses. The main volume of venous outflow is carried out along deep highways. Superficial trunks carry away only 20-25% of the blood from the lower extremities.

Of greatest interest are the deep veins of the lower leg. It is in them that the formation of blood clots most often occurs. This is due to the presence of many venous cisterns and sinuses that form with the veins of the muscle pump of the leg. They act as natural blood depots. The lower leg, being the distal segment of the body, is constantly immobilized, which contributes to stagnation of blood. This is the trigger mechanism for thrombosis, determining the prognosis for deep vein thrombosis of the lower extremities.

Causal mechanisms of development

The risk group for the development of this disease includes:

Varicose transformation of veins with decompensated insufficiency of perforating veins;
Sedentary work with a sedentary lifestyle;
Taking oral combined oral contraceptives;
Operations on limbs, pelvic and abdominal organs;
Fractures of large bones of the lower limb;
Tumors of the abdominal cavity, pelvis and retroperitoneal space;
Dyshormonal conditions from the endocrine and reproductive systems;
Positional compression syndrome.

The central link in the pathogenesis that determines the symptoms of deep vein thrombosis of the lower extremities is blood stasis, in which accelerated blood clotting occurs. Thrombi form, obliterating the lumen of the vein. Venous outflow is obstructed, with the occurrence of venous hypertension in the deep system below the site of obstruction.

Features of clinical manifestations

Symptoms of deep vein thrombosis of the lower extremities consist of anamnestic data, patient complaints, objective examination data and additional research methods.

The presence of risk factors for the development of this disease in patients is always alarming, suggesting the possibility of developing phlebothrombosis. Modern phlebologists use special scales that determine the risk of developing the disease as a percentage.

All patients with phlebothrombosis complain of severe swelling of the lower extremities, accompanied by pain. Movements and attempts to walk cause them to increase, which is why patients spend most of their time in a supine position. The biggest pains are localized in the calf muscles.

The data of examination and palpation help to identify such signs that depend on the level of thrombosis and determine the tactics in the treatment of deep vein thrombosis of the lower extremities:

Ileofemoral - localization in the iliac-femoral segment;
Femoral - thrombosis of the femoral segment;
Femoral popliteal phlebothrombosis;
Phlebothrombosis of the leg.

This forms the clinical picture. The higher the localization of vein stenosis, the higher the level of pathological changes determined during examination. They are reduced to a woody edema of the affected segment of the lower leg and thigh compared with a healthy limb, discoloration of the skin in the form of cyanosis and hyperemic spots. Pain is determined by palpation during anterior-posterior compression of the lower leg (positive symptom of Homans), and its intensification by flexion-extension of the foot (positive symptom of Moses). These data are specific for phlebothrombosis of the lower extremities when combined with severe edema.

For laboratory diagnostics, a study of blood coagulation is carried out: platelets, prothrombin index, clotting time and duration of bleeding, coagulogram, fibrinogen, prothrombin and active partial thromboplastin time. Instrumental diagnostics consists in ultrasound examination with Doppler amplification of the lower extremities with the determination of their patency and blood flow intensity.

Treatment

Choosing the treatment of deep vein thrombosis of the lower extremities, take into account the pathogenesis. Therefore, the composition of complex therapy includes:

Immobilization of the affected limb with a Beller tire with an elevated position of the foot;
Elastic bandaging and compression stockings;
Anticoagulant drugs and antiplatelet agents: heparin, fraxiparin, clexane, ticlopidine, clopidogrel;
Rheological and vascular preparations: reosobilact, pentoxifylline, tivortin, trental. They are included as basic in the treatment of thrombosis of the lower extremities;
Prostaglandin preparations: alprostan, vazaprostan, ilomedin;
Non-steroidal anti-inflammatory drugs: dicloberl, olfen, melbek;
Glucocorticoids in small doses: dexamethasone, methylprednisolone.

Treatment of thrombosis of the lower extremities is carried out under the control of blood coagulation parameters. If there is a risk of thrombus migration into the vessels of the lungs with the development of pulmonary embolism, femoral vein catheterization is performed with the placement of a cava filter, which will become an obstacle to the spread of blood clots.

The prognosis for deep vein thrombosis of the lower extremities is a post-thrombophlebitic disease, gradually decreasing with recanalization of the affected vein.

Causes, risk factors for superficial thrombophlebitis and deep vein thrombosis

Disorders of the blood coagulation system (thrombophilia), which can be inherited from parents or appear as a reaction of any acquired pathology, are one of the causes of the formation of a blood clot. In addition, there are a number of risk factors that contribute to the formation of a blood clot in the venous bed of the lower extremities:

prolonged immobility (for example, in a hospital bed);
excesses of DVT and/or embolism in the past;
some types of cancer;
obesity;
Varicose veins.

The risk of deep vein thrombosis increases dramatically in the postoperative period, especially for hip and knee surgery. During pregnancy and 6 months after childbirth, due to hormonal changes in the body, increased blood clotting is observed. The same problem can occur in young women or older than 40 if they are taking hormonal drugs (birth control pills or replacement therapy). Some experts believe that air travel can cause DVT, which is associated with prolonged periods of immobility coupled with dehydration, especially when aggravated by alcohol.

Superficial thrombophlebitis may appear after an insect bite, with trauma to the skin. A banal cut, if left untreated, sometimes causes inflammation of the vein. Also, thrombophlebitis is often found in drug addicts who use the vessels of the legs to administer drugs.

Diagnosis of pathologies

Specific tests help identify hereditary subtypes of thrombophilia. For certain types of bleeding disorders, the patient may be offered a permanent intake of drugs that prevent blood clots.

Diagnosis of superficial thrombophlebitis, as a rule, does not cause difficulties. If DVT is suspected, ultrasound of the venous system (duplex sonography) is usually done. Less commonly used magnetic resonance venography or computed tomography. Although these techniques are considered to be highly informative in diagnosing the pathology of the deep veins of the lower extremities, their high cost does not allow them to be widely used in clinical practice.

Magnetic resonance venography (MRI)

A blood test, known as a D-dimer test, is also sometimes used if a pulmonary embolism is suspected. When diagnosing this serious complication, CT (computed tomography) is usually performed.

thrombophlebitis of superficial veins

From it you will learn about the causes and localization of pathology, risk factors, complications, diagnosis and treatment options.

Differences in treatment

Superficial thrombophlebitis and deep vein phlebothrombosis have different therapeutic approaches. As a rule, at the first time, patients do not need hospitalization. Bed rest is recommended with a raised affected limb, local heat and compresses with antiseptics (dimexide, dioxidine). Anti-inflammatory drugs are given either orally or as a cream or gel (eg, Hirudoid®).

Treatment of deep vein thrombosis is carried out in a hospital, which usually includes injections of low molecular weight heparin. The action of these drugs is aimed at preventing a further increase in blood clot, the appearance of new ones. Sometimes he resorts to surgical intervention: a blood clot is removed or a special filter is installed in the inferior vena cava. The main goal of treatment is to prevent pulmonary thrombosis.

Today, surgeons, as a rule, use the term “thrombophlebitis” to describe the inflammatory process in the saphenous veins, and “phlebothrombosis” to refer to deep lesions. Nevertheless, as microstudies show, in these pathologies, changes in the vascular wall are identical. It was also found that quite often the inflammatory process can move from superficial to deep vessels. Many therapists believe that superficial thrombophlebitis is a commonplace disease that does not pose a serious threat to the patient's health. From this follows a practical conclusion for the patient: no matter what the diagnosis is - superficial thrombophlebitis or deep vein thrombosis - in any case, you should contact a specialist. It is best to see a phlebologist.

Diseases thrombophlebitis and phlebothrombosis are characterized by intravital formation of a thrombus in the lumen of a venous vessel, accompanied by characteristic signs and changes in blood flow.

Despite the consonance of these terms, they are completely different in content.

Thrombophlebitis

˗ this is an acute disease of the superficial veins, accompanied by inflammation of the vessel wall.

Phlebothrombosis affects deep veins without inflammation of the vascular wall. Let us examine in more detail the differences between thrombophlebitis and phlebothrombosis.

Phlebothrombosis

A condition that develops when blood clots form in deep veins. The reasons are:

diseases that cause changes in blood clotting;
surgical interventions, including dental;
diseases of the lungs and heart, leading to stagnation of blood and increased formation of blood clots;
prolonged forced immobilization after strokes or injuries;
damage to the inner lining of blood vessels by microbial, pharmacological or chemical factors.

Circumstances that contribute to the development of thrombosis:

The manifestations of the disease depend on the location of the thrombus and which vessel is damaged. Unlike acute thrombophlebitis, they are less pronounced and the diagnosis is more difficult to make. But there are symptoms, the appearance of which should immediately consult a doctor:

the appearance of severe pain in the calf muscles, aggravated by movement;
swelling of the lower leg and ankle;
redness of the skin, accompanied by pain in the muscles;
pain, swelling, redness of large joints;
expansion of subcutaneous vessels.

These signs will be different in severity and located in different places. If a blood clot is in the deep veins of the lower leg, then swelling, expansion of the vascular pattern will be on the legs.

If thrombosis of the inferior vena cava develops, then the swelling will be in the lumbar region, and the superficial veins will expand on the abdomen. In any case, if such symptoms appear, you should immediately seek medical help.

Thrombophlebitis

The pathology of superficial vessels rarely begins on its own. More often it is a complication of the course of varicose veins. Clinical course in acute subacute and chronic form ˗ phlebothrombosis and thrombophlebitis what is the difference?

Anatomically, the cause of thrombophlebitis is a malfunction of the lymphatic and blood vessels, causing a violation of the blood flow and the formation of blood clots. Mostly small and large saphenous veins are affected. Conditions that “help” the onset of the disease:

surgical interventions and injuries;
pregnancy and childbirth;
purulent-septic diseases;
allergic reactions.

Signs:

along the superficial vessels there are painful seals resembling a cord;
swelling of surrounding tissues;
skin redness;
excessive blood filling of superficial vessels;
deterioration in general well-being (chills, weakness, sweating).

The severity of symptoms gradually increases. "Bruises" form along the veins, dense nodules are felt when probing. The pain intensifies and spreads, swelling increases. All of the above is a reason to urgently contact a phlebologist.

Despite the differences in the mechanisms of development and symptoms of these two conditions, there are similarities.

Treatment of thrombosis

Effective treatment of both pathologies combines the prescription of drugs that prevent the formation of new blood clots and dissolve existing ones, and surgical removal of blood clots. Only with such a combined approach can recovery be achieved.

Diseases of the facial vessels

The isolation of phlebitis, thrombophlebitis and phlebothrombosis of the veins of the face is due to the fact that narrow specialists in the field of maxillofacial surgery are engaged in the treatment of these diseases. A few words about the causes of these diseases.

The disease of superficial facial veins develops as a complication of inflammatory processes of facial tissues (boils, carbuncles, acne). It manifests itself in the same way as thrombophlebitis of the lower extremities, but with more pronounced signs of intoxication.

Deep facial veins are affected in the complication of trauma and dental interventions (tooth extraction). Complication is extremely rare. Modern dentistry of phlebitis, thrombophlebitis and phlebothrombosis has practically excluded the development of these pathologies. Diagnosing it is extremely difficult and often it ends with a person's disability or death.

What are the differences from phlebitis?

The view of these two pathological conditions as completely different has developed a very long time ago. But this position has not stood the test of time. Modern phlebology has proven that there are no significant differences in their development.

Inflammation of the vessel wall leads to the formation of a thrombus, and blockage by a thrombus leads to the development of inflammation. It is impossible to determine what is primary and what is secondary.

With regard to phlebitis and thrombosis, this is reminiscent of reasoning about the chicken and the egg. Paying tribute to traditions, doctors use the term "phlebothrombosis" to refer to damage to deep veins, and "thrombophlebitis" to superficial ones.

In practice, only one thing is important: a disease that began with superficial vessels can, at any moment, spread to deep ones. Lead to the development of life-threatening conditions. And the main task of the phlebologist is to prevent this.

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Thrombophlebitis and phlebothrombosis are often considered synonyms, the names of the same disease. Actually it is not. Despite the somewhat similar etiology, these are different pathologies. So what is the difference between thrombosis and thrombophlebitis? What factors influence their development? What are the symptoms of venous involvement in the first and second cases?

1 Specificity of diseases

The main difference between thrombosis and thrombophlebitis is the place of localization. Thrombophlebitis usually develops in superficial venous vessels, while thrombosis often affects deep veins. In addition, with thrombophlebitis, blood clots form in deformed vessels, while thrombosis can occur in unchanged, normal veins.

The cause of pathological changes in the veins, as a rule, is varicose veins, damage to the inner walls of the blood vessel due to trauma, infection (local, general), etc. As a result of damage, the blood flow through the vein is disturbed, slowed down. As a result, this leads to inflammation of the vessel, the formation of dense blood clots in it, which further interferes with the passage of blood through the veins, inflammation of the soft tissues of the lower or upper extremities.

Thrombosis is considered a much more dangerous disease. For him, as well as for thrombophlebitis, the formation of blood clots in the veins is characteristic, preventing the normal passage of blood through the vessels. However, deep vein phlebothrombosis, in the first place, occurs due to a violation of the coagulation properties of the blood itself, and not damage to blood vessels.

Thrombosis and thrombophlebitis mainly differ in that the former can occur in a non-inflamed vein. This explains the frequent absence or low severity of symptoms of pathology.

As for thrombophlebitis, it is much easier to identify it. The disease occurs against the background of an inflammatory process in the vein, therefore, it is almost always accompanied by local and general inflammation-specific phenomena.

Reasons for the development of hypoplasia of the right vertebral artery, consequences and methods of treatment

2 Causes of pathologies

There are no significant differences in the etiology of the diseases. Multiple factors contribute to the formation of blood clots in both cases. Regardless of the location of the pathology, both thrombosis and thrombophlebitis occur against the background of:

Varicose disease.
Vascular diseases.
Damage to the venous walls.
Pathologically altered blood composition.
Increased blood clotting.
Slow blood flow.

In turn, the reasons for the development of such conditions are:

Endocrine diseases.
Oncological diseases.
Chronic diseases of the cardiovascular system.
General and local infectious diseases.
Diseases of the blood.
neurotrophic disorders.
allergic processes.
Intravenous injections that damage a blood vessel.
Vein catheterization for a long time.
Operations performed in the area of the hip joint, pelvic floor, lower abdominal cavity.
Local inflammatory, purulent processes.
Wrong nutrition.
Bad habits.
Violation of the processes of general metabolism.
Failures of hormonal regulation.
abortion.
Pregnancy, childbirth.

Most often, thrombophlebitis develops in deformed veins. Deformation of blood vessels occurs due to excessive loads on the hip joints, legs (weight lifting, prolonged standing, etc.). Accordingly, active people who are exposed to excessive physical exertion are at risk.

But the lack of movement is also unhealthy. A sedentary lifestyle, sedentary work lead to the formation of phenomena of blood stagnation in the veins of the lower extremities. The consequence of such conditions is a violation of normal blood flow, expansion, deformation of the veins, the formation of blood clots and blood clots in their lumens.

3 Main symptoms and signs

The main symptom of phlebothrombosis is a sudden flash of pain in the affected limb. Pain is not constant, but is aggravated by loads on the legs (walking, lifting weights, standing for a long time).

Next, tissue swelling occurs. There is a feeling of heaviness, fullness of the legs. The skin around the thrombosed area of the vein is cyanotic (cyanotic), strongly stretched, shiny. Expanded tense veins become noticeable a few days after the formation of a blood clot.

The temperature of the limb rises by 1.5-2 degrees. An increase in general body temperature is possible. The pulsation of the arteries of the diseased limb may not be disturbed, but most often it is felt weakly or completely absent.

With thrombosis of the gastrocnemius or only deep veins, the clinical picture of the disease is erased. In such cases, the only symptom of the pathology that has arisen is a slight swelling in the ankle joint and pain in the calf muscle that occurs during physical exertion.

In acute thrombophlebitis of the superficial veins, the first symptoms are painful sensations of a pulling nature. The pain is localized in the area of the thrombosed area of the blood vessel. The affected vein is sealed, protrudes above the surface of the skin. Unlike thrombosis, arterial pulsation and limb temperature remain normal.

There is swelling of the sore leg, motor functions are difficult. In the course of a thrombosed vein, swelling, infiltration, and hyperemia of soft tissues are observed. The skin takes on a bluish tint. Varicose veins are tense, with palpation of the affected areas there is severe pain.

Specific signs of thrombophlebitis are often accompanied by inflammatory symptoms:

1. deterioration of health;
2. general weakness;
3. chills;
4. headache;
5. increased body temperature (in severe cases up to 39 degrees).

Thrombophlebitis of deep veins is manifested by uniform swelling of the foot and lower leg. The pain is dull, increases sharply when you press on the calf muscle, when bending the foot. The patient can walk with difficulty. Sometimes the pain is so severe that the person cannot step on the foot.

If any of the above symptoms appear, it is necessary to consult a phlebologist. Undergo a medical examination and, if thrombophlebitis or thrombosis is detected, immediately begin adequate treatment under the guidance of a doctor.

Only a specialist can distinguish phlebothrombosis and thrombophlebitis by characteristic symptoms, since they have a similar etiology and in order to make an accurate diagnosis, it is necessary to know exactly the specifics of each disease.

The difference between the two diagnoses

With the development of thrombophlebitis, blood clots appear in deformed veins, and thrombosis can occur in any venous vessel that does not have any changes.

Thrombophlebitis and phlebothrombosis appear on the walls of deep veins. But the first can develop on the superficial vein, and the second appears only on the walls of the deep veins.

Usually, pathological changes in the venous channels begin to develop due to varicose veins themselves, damage to the inner walls of blood vessels due to various injuries, the development of infection, and many other reasons. All this slows down blood circulation in the venous channels, and stagnation leads to inflammatory processes. Blood clots appear, which quickly harden, forming blood clots. This leads to complete stagnation of blood, inflammation of the soft tissues of the legs or arms.

Unlike thrombophlebitis, thrombosis is considered more dangerous, since with it blood clots can develop due to the slightest damage to the vein. And phlebothrombosis with thrombophlebitis appear due to changes in the properties of the blood itself.

Factors affecting the appearance of pathologies

the development of varicose ailments;
various vascular diseases;
injury to the walls of the vein;
pathology with a change in the composition of the blood, an increase in its coagulability;
slowdown and stagnation in the blood flow.

Symptoms of various lesions of the veins

If thrombosis of deep veins or gastrocnemius vessels begins, then the symptoms are usually erased, since in most cases a sign of the disease is a small swelling in the ankle joint area and slight soreness in the calves during physical exertion.

Thrombophlebitis is accompanied by the following signs of inflammation: the patient begins to feel sharply worse, he complains of general weakness, pain in the head, he is tormented by chills. A significant increase in temperature is possible - up to 38-40ºС.

If at least one of the above symptoms occurs, you should seek help from a doctor of the appropriate specialty (phlebologist).

For citation: Givirovskaya N.E., Mikhalsky V.V. Thrombosis and thrombophlebitis of the veins of the lower extremities: etiology, diagnosis and treatment // RMJ. 2009. No. 25. S. 1663

Venous thrombosis is an acute disease caused by blood clotting in the lumen of a vein, which leads to a violation of its patency. It is necessary to distinguish between the concepts of "thrombophlebitis" and "phlebothrombosis". Phlebitis is an inflammation of the vein wall due to a general or local infection. Phlebothrombosis develops due to changes in the coagulation properties of blood, damage to the vascular wall, slowing down blood flow, etc. .

Introduction

Acute deep vein thrombosis and thrombophlebitis of the superficial veins of the lower extremities are common diseases and occur in 10–20% of the population, complicating the course of varicose veins in 30–55% of cases. In the vast majority of cases, thrombophlebitis is localized in superficial veins. Deep vein thrombosis of the lower extremities develops in 5-10% of cases. An extremely life-threatening situation occurs with a floating thrombus due to the development of pulmonary embolism (PE). The floating tip of the thrombus has high mobility and is located in an intense blood flow, which prevents its adhesion to the walls of the vein. Detachment of a venous thrombus can lead to massive thromboembolism (immediate death), submassive pulmonary embolism (severe hypertension in the pulmonary circulation with pressure values in the pulmonary artery of 40 mm Hg and above) or thromboembolism of small branches of the pulmonary artery with a clinical presentation of respiratory failure and the so-called pneumonia infarction. Floating thrombi occur in about 10% of all acute venous thromboses. Pulmonary embolism is fatal in 6.2% of cases.

No less important are other consequences of lower extremity vein thrombosis, which after 3 years in 35-70% leads to disability due to chronic venous insufficiency against the background of post-thrombophlebitic syndrome.

Etiology

Venous thrombosis is polyetiological. In the pathogenesis of thrombus formation, disturbances in the structure of the venous wall, a slowdown in blood flow velocity, an increase in the coagulation properties of blood (Virchow's triad) and a change in the magnitude of the electrostatic potential between the blood and the inner wall (Z potential) are important.
According to the etiology, venous thrombosis is distinguished:
congestive (with varicose veins of the lower extremities, due to extravenous compression of the veins and intravenous obstruction of blood flow);
inflammatory (post-infectious, post-traumatic, post-injection, immuno-allergic);
in case of violation of the hemostasis system (with oncological diseases, metabolic diseases, liver pathology).
By localization:
thrombophlebitis of the superficial veins of the lower extremities (the main trunk of the large, small saphenous veins, tributaries of the saphenous veins and their combinations);
deep vein thrombosis of the lower extremities (tibia-popliteal segment, femoral segment, iliac segment and their combinations).
According to the connection of the thrombus with the wall of the vein, options are possible:
occlusive thrombosis,
parietal thrombosis,
floating,
mixed.

The clinical picture of thrombosis and thrombophlebitis of the veins of the lower extremities

Acute thrombophlebitis of the superficial veins of the lower extremities often develops in the large, rather than in the small, saphenous vein and its tributaries and is, as a rule, a complication of varicose veins. For him, the severity of local inflammatory changes in the area of the affected saphenous veins is typical, so its diagnosis is simple and accessible. Spontaneous thrombophlebitis without varicose veins is often the result of gynecological pathology or the first symptom of a malignant neoplasm of the gastrointestinal tract, prostate, kidneys and lungs. The first manifestation of the disease is pain in the thrombosed area of the vein. Along the course of the compacted vein, hyperemia of the skin appears, infiltration of surrounding tissues, a picture of periphlebitis develops. Palpation of the thrombosed area of the vein is painful. There may be a deterioration in general well-being, manifested by symptoms of a general inflammatory reaction - weakness, malaise, chills, an increase in body temperature to subfebrile numbers, and in severe cases up to 38-39 ° C. Regional lymph nodes are usually not enlarged.

The most characteristic clinical sign of acute deep vein thrombosis of the lower extremities is a sudden onset of pain, aggravated by physical exertion (walking, standing). Then there is swelling of the tissues, accompanied by a feeling of fullness and heaviness in the limb, an increase in body temperature. The skin distal to the site of thrombosis is usually cyanotic, shiny. The temperature of the affected limb is 1.5–2°C higher than that of the healthy one. The pulsation of the peripheral arteries is not disturbed, weakened or absent. On the 2-3rd day from the onset of thrombosis, a network of dilated superficial veins appears.

Deep vein thrombosis with the involvement of only the veins of the gastrocnemius muscles or 1-2 deep main veins is accompanied by an erased clinical picture. The only sign of thrombosis in such cases is pain in the calf muscles and slight swelling in the ankle area.
Clinical manifestations of thrombophlebitis of the superficial veins of the lower extremities and deep vein thrombosis are not always specific. In 30% of patients with superficial thrombophlebitis, the true prevalence of thrombosis is 15–20 cm higher than clinically detectable signs of thrombophlebitis. The rate of thrombus growth depends on many factors and in some cases it can reach 20 cm per day. The moment of transition of thrombosis to deep veins proceeds secretly and is not always determined clinically.
Therefore, in addition to the data of general clinical examination, the presence of thrombosis of the veins of the lower extremities is confirmed on the basis of special diagnostic methods.

Methods for diagnosing deep thrombosis and thrombophlebitis of the superficial veins of the lower extremities

There are many methods for examining the venous system of the lower extremities: Doppler ultrasound, duplex scanning, phlebography, CT phlebography, photoplethysmography, phleboscintiography, phlebomanometry. However, among all instrumental diagnostic methods, ultrasonic angioscanning with color blood flow mapping has the maximum information content. To date, the method is the "gold" standard for diagnosing vein pathology. The method is non-invasive, it allows to adequately assess the state of the vein and surrounding tissues, determine the localization of the thrombus, its extent and the nature of thrombosis (floating, non-occlusive parietal, occlusive), which is extremely important for determining further treatment tactics (Fig. 1).

In cases where ultrasound methods are not available or are of little information (thrombosis of the ileocaval segment, especially in obese patients and in pregnant women), radiopaque methods are used. In our country, retrograde iliocavagraphy is the most widely used. Using subclavian or jugular access, a diagnostic catheter is inserted into the inferior vena cava and iliac veins. A contrast agent is injected and angiography is performed. If necessary, a cava filter can be implanted from the same access. In recent years, minimally invasive radiopaque techniques have begun to be used - helical computed tomoangiography with 3D reconstruction and magnetic resonance tomoangiography.
From laboratory studies, venous thrombosis can be suspected by detection of critical concentrations of fibrin degradation products (D-dimer, SFMC - soluble fibrin-monomeric complexes). However, the study is not specific, since RFMK and D-dimer also increase in a number of other diseases and conditions - systemic connective tissue diseases, infectious processes, pregnancy, etc.

Treatment of patients with thrombophlebitis and thrombosis of the veins of the lower extremities

Treatment of patients with thrombophlebitis and thrombosis of the veins of the lower extremities should be comprehensive, including conservative and surgical methods.
From November 2008 to October 2009 in the City Clinical Hospital No. 15 named after. O.M. Filatov hospitalized 618 patients with acute pathology of the veins of the lower extremities. Of these, men - 43.4% (n=265), women - 66.6% (n=353). The average age was 46.2 years. Ascending thrombophlebitis of the great saphenous vein was observed in 79.7% (n=493), deep vein thrombosis of the lower extremities - in 20.3% (n=125) of patients.
All patients underwent conservative therapy aimed at improving microcirculation and rheological properties of blood, suppressing the adhesive-aggregation function of platelets, correcting venous blood flow, providing anti-inflammatory and desensitizing effects. The main objectives of conservative treatment are the prevention of continued thrombus formation, the fixation of a thrombus to the walls of the vessel, the elimination of the inflammatory process, as well as the impact on microcirculation and tissue metabolism. An important condition for treatment is to provide the limb with functional rest and prevent thromboembolic complications. For this purpose, patients in the early period of the disease are prescribed bed rest with an elevated position of the lower limb. With deep vein thrombosis of the lower leg, the duration of bed rest is 3-4 days, with iliac-femoral thrombosis - 10-12 days.
However, the main one is anticoagulant therapy with strict laboratory monitoring of hemostasis system parameters. At the onset of the disease, direct anticoagulants (heparin or low molecular weight heparin - fraxiparin) are used. The following scheme of heparin therapy is most often used: 10 thousand units of heparin intravenously and 5 thousand units intramuscularly every 4 hours on the first day, on the second day - 5 thousand units every 4 hours, then 5 thousand units of heparin every 6 h. By the end of the first week of treatment, the patient is transferred to indirect anticoagulants (blockers of the synthesis of vitamin K-dependent coagulation factors): 2 days before heparin therapy is discontinued, patients are prescribed indirect anticoagulants, and the daily dose of heparin is reduced by 1.5–2 times due to a decrease in single dose. The effectiveness of heparin therapy is controlled by such indicators as bleeding time, clotting time and activated partial thromboplastin time (APTT), anticoagulant therapy with indirect anticoagulants - prothrombin index (PTI), international normalized ratio (INR).

To improve microcirculation and rheological properties of blood, all patients received intravenous administration of pentoxifylline (original drug Trental® by Sanofi-Aventis) 600 mg/day, which is a derivative of methylxanthine. Currently, the drug is one of the most frequently and successfully used drugs in angiological practice, it is included in the standards for the treatment of patients with venous and arterial pathology. As a result of the use of pentoxifylline, an improvement in microcirculation and oxygen supply to tissues is noted. The mechanism of action of pentoxifylline is associated with the inhibition of phosphodiesterase and the accumulation of cAMP in vascular smooth muscle cells, in blood cells. Pentoxifylline inhibits the aggregation of platelets and erythrocytes, increases their flexibility, reduces the increased concentration of fibrinogen in plasma and enhances fibrinolysis, which reduces blood viscosity and improves its rheological properties. In addition, pentoxifylline has a weak myotropic vasodilating effect, somewhat reduces the total peripheral vascular resistance and has a positive inotropic effect. It was also found that the drug inhibits cytokine-mediated activation of neutrophils and adhesion of leukocytes to the endothelium, reduces the release of oxygen free radicals.

Operative treatment is necessary if there is a risk of developing pulmonary embolism.
In acute thrombophlebitis of the superficial veins, indications for surgical treatment occur when a thrombus grows along the great saphenous vein above the level of the middle third of the thigh. The classic variant of the operational aid is the Troyanov-Trendellenburg operation or its modification - crossectomy. The Troyanov-Trendelenburg operation consists in the ostium ligation of the great saphenous vein and the intersection of its trunk within the wound, which prevents the spread of the thrombotic process to the femoral vein. Crossectomy differs in that all the ostium tributaries of the great saphenous vein are additionally isolated and tied up, as a result of which the possibility of reflux through the saphenofemoral fistula is eliminated. Surgical treatment in the form of crossectomy was performed in 85.4% (n=421) of patients. The Troyanov-Trendellenburg operation was not performed. In 7.4% (n=31) of patients during surgery, it was necessary to perform thrombectomy from the common femoral vein in the presence of ultrasound signs of prolapse of the thrombus head through the saphenofemoral fistula. There were no deaths in these patients.

The indication for surgical treatment of patients with acute deep vein thrombosis of the lower extremities is the presence of signs of thrombus head flotation, detected by ultrasound. The floating nature of thrombosis was verified in 29.6% (n=37) of patients. The choice of operation depends on the level of the proximal border of the thrombus. Damage to the deep veins of the legs was observed in 14.4% (n=18), the veins of the popliteal-femoral segment - in 56.8% (n=71), the iliac veins - in 23.2% (n=29), the inferior vena cava – in 5.6% (n=7) of patients. Surgical treatment was performed in 48.6% (n=18) of patients. Ligation of the femoral vein was performed in 30% (n=6) of patients when a floating thrombus was detected in the popliteal vein. In 44.4% (n=8) of patients, embolectomy from the common femoral vein and ligation of the femoral vein were performed to verify the presence of a floating thrombus in the common femoral vein. A cava filter was installed in the inferior vena cava in 25.6% (n=4) of patients with floating thrombosis of the iliac veins or inferior vena cava below the level of the renal veins. There were no cases of lethality in operated patients with deep vein thrombosis of the lower extremities. In the group of patients with conservative therapy of deep vein thrombosis of the lower extremities, 4 patients (3.2%) died.

Conclusion

Currently, the problem of treating patients with thrombophlebitis and thrombosis of the veins of the lower extremities is relevant. This is due to the predominant occurrence of diseases at working age, frequent disability of the patient, especially after deep vein thrombosis due to the development of post-thrombophlebitic syndrome, and the risk of death in the development of pulmonary embolism. All patients need conservative therapy, which is based on anticoagulant drugs that prevent the progression of the process or the development of retrombosis. To improve microcirculation and rheological properties of blood, patients need to use pentoxifylline at a dosage of 600 mg / day, which causes a rapid decrease or disappearance of edema and pain in the affected limb. Operative methods of treatment are indicated in the presence of a threat of PE. At the same time, in patients with ascending thrombophlebitis of the veins of the lower extremities, crossectomy is necessary. The choice of surgery in the presence of a floating thrombus in the deep veins of the lower extremities depends on the level of the proximal border of thrombosis and includes ligation of the femoral vein, embolectomy from the common femoral vein with ligation of the femoral vein, implantation of a cava filter into the inferior vena cava. It should be noted that all patients with identified deep vein thrombosis of the lower extremities should be considered as patients with a high risk of developing PE (even in the absence of signs of thrombus head floatation) and receive adequate therapy in combination with control ultrasound.

Literature

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