Thrombophlebitis etiology. Thrombophlebitis: clinical signs and principles of treatment. Risk factors for DVT include

Etiology and pathogenesis. In the development of thrombophlebitis, a number of factors are important: changes in the body’s reactivity, neurotrophic and endocrine disorders, damage to the vascular wall, infection, changes in the biochemical composition of the blood, slowing of blood flow (for example, in heart failure) and venous stasis. Thrombophlebitis often develops against the background of varicose veins (see full body of knowledge). Often the occurrence of Thrombophlebitis is preceded by various surgical interventions, mainly on the pelvic organs and in the inguinal-iliac areas, complicated abortions and childbirth (the so-called postpartum Thrombophlebitis, which develops as a result of metroendometritis or adnexitis complicating childbirth), malignant tumors, trauma and wounds, prolonged venous catheterization

The role of infection in the development of thrombophlebitis is complex. Some researchers believe that the infectious agent acts directly on the wall of the vein, entering it either through the bloodstream or from a nearby inflammatory focus. Others consider the effect of the infection as generally toxic, affecting the entire vascular system, disrupting the function of the coagulation and anticoagulation systems of the blood. If the purulent process involves the vessels supplying the venous wall (vasa vasorum), the vein may melt (purulent thrombophlebitis).

Primary inflammation occurs, apparently, as a consequence of the reaction of the venous wall to irritants of infectious, allergic

(autoimmune) or tumor in nature, arriving through the lymphatic vessels, capillaries of the vascular wall and perivascular spaces. The damaging agent causes not only damage to the endothelium of the venous system and activation of the blood coagulation process (see the complete body of knowledge: Blood coagulation system), it affects the complement system (see the complete body of knowledge) and the kinin system (see the complete body of knowledge: Kinins), which have common activators and inhibitors; leads to a change in the protein-forming function of the liver with a predominance of the synthesis of procoagulants, fibrinolysis inhibitors, a decrease in the production of heparin and activators of the fibrinolytic link of the hemostasis system (see full body of knowledge). These disorders ultimately lead to a thrombotic state characterized by significant hypercoagulability, marked inhibition of fibrinolysis, and increased platelet and erythrocyte aggregation. This condition predisposes to the formation of a blood clot and its active growth in the affected vessels.

Pathological anatomy. Features of the morphogenesis of Thrombophlebitis depend on the relationship between the processes of inflammation and thrombosis (see full body of knowledge). The inflammatory process in the vein wall can precede thrombosis, developing in the inner lining of the vessel (endophlebitis) or spreading from the tissues surrounding the vein (periphlebitis), and gradually affecting the entire thickness of the vein wall (panphlebitis). The onset of thrombosis is usually associated with endothelial damage. However, another way is also possible: if hemodynamics in the vein are disturbed, as well as with pathology of the blood coagulation system, phlebothrombosis occurs, which is accompanied by inflammatory changes in the wall, usually its inner lining. Endophlebitis in combination with thrombosis is called endothrombophlebitis. Thrombophlebitis developing on the basis of periphlebitis is called peritrombophlebitis; more often it occurs during suppurative processes - boils, abscesses, phlegmon (color figure 11).

With endothrombophlebitis, the vein wall is hyperemic, edematous, its inner layer is moderately infiltrated with polymorphonuclear leukocytes. The endothelial layer of the wall is absent, thrombotic masses are adjacent to it. Collagen and elastic fibers are not changed, the outer shell of the wall and perivascular connective tissue are intact.

In some cases, the intensity of infiltration of the vein wall with polymorphonuclear leukocytes over some distance can be significant. In this case, the inner layers of the wall are melted; its structural elements in these areas cannot be traced; a blood clot, which contains a significant number of leukocytes, is directly adjacent to the necrotic area. The leukocyte infiltrate, gradually decreasing, spreads to the outer membrane of the wall; in accordance with the decrease in infiltration, destructive changes decrease. Vasa vasorum thrombosis occurs only when inflammatory infiltration covers all layers of the vein wall, including the outer ones.

With peritrombophlebitis, the outer lining of the vein wall and vasa vasorum are primarily affected. The vein wall is thickened, gray-yellow in color, with areas of hemorrhage. Leukocyte infiltration spreads from the perivascular connective tissue to the outer, then middle and inner membranes of the vessel. The walls of the vasa vasorum, around which the most intense infiltration is noted, undergo necrosis, and their lumen becomes thrombosed. Poor circulation in the vasa vasorum system leads to the development of dystrophic and necrotic changes in the vein wall. Against this background, inflammatory infiltration intensifies, the spread of which to all layers of the wall ends with the formation of first a parietal and then an occlusive thrombus.

Thrombophlebitis in sepsis (see full body of knowledge) is characterized by purulent inflammation of the inner lining of the vessel; microbial colonies are found in thrombotic masses infiltrated with leukocytes. They are often located not only in thrombotic masses, but also in the middle and outer membranes of the vein, which leads to the formation of microabscesses. Subsequently, the thrombotic masses undergo purulent melting together with the adjacent sections of the vein wall. Septic thrombophlebitis becomes a source of generalization of infection, the development of thrombobacterial embolism (see full body of knowledge: Embolism) and purulent-destructive changes in various organs and tissues.

With a favorable course of acute thrombophlebitis, resorption of necrotic masses occurs, polymorphonuclear leukocytes disappear, and macrophages, lymphocytes, plasma cells, and fibroblasts appear instead. Loose young granulation tissue develops (see full body of knowledge), and then the organization or canalization of the thrombus occurs, the maturation of granulation tissue (color figure 12) and its transformation into coarse fibrous connective tissue. If a lumen remains in the vessel and the wall remains mobile, it is possible to restore elastic fibers and form from them membrane-like structures that have an irregular shape and uneven folding. When the lumen of a vessel is obliterated, few elastic fibers are formed; they do not form into membrane-like structures. The newly formed collagen fibers both in the vein wall and in the thrombus are located in a non-oriented manner. Smooth muscle cells are not restored, and the remaining ones are located in groups among the fibrous structures. After completing the organization process, it is not possible to microscopically determine the boundary between the altered venous wall and the fibrous tissue that has developed at the site of the thrombus. Often, in fibrous-changed tissues of the vein wall, areas of hyalinosis (see full body of knowledge) and calcification (see full body of knowledge) are detected.

The outcome of Thrombophlebitis is sclerosis (see full body of knowledge) of the venous wall and thrombus. The vein takes on the appearance of a dense whitish tube or cord. The degree of restoration of the vein lumen in thrombophlebitis depends on the size of the thrombus. During the process of scarring, a small wall thrombus merges with the wall, making it thicker, blocking the venous valves, but without interfering with blood flow, that is, almost complete restoration of the lumen occurs. A thrombus that covers most of the lumen of the vein turns into a thick connective tissue cushion as the connective tissue matures; the lumen of the vessel narrows unevenly, in places acquiring a slit-like shape. A thrombus obstructing the lumen of the vein, after completion of organization, leads to obliteration of its lumen. In the connective tissue that replaces the thrombus, you can find cracks and channels lined with endothelium and containing blood. The degree of restoration of blood flow to a certain extent depends on their volume.

Periphlebitis, which develops with Thrombophlebitis, can be the cause of sclerosis of the connective tissue surrounding the neurovascular bundle, and therefore the latter ends up in a dense fibrous sheath. It is possible that this case, especially when petrified, is important in the development of neurotrophic disorders in postthrombophlebitic syndrome (see full body of knowledge: below).

Changes in organs and tissues during thrombophlebitis depend on the location and severity of the process. Venous stagnation leads to the development of dystrophic, atrophic, sclerotic changes in the surrounding tissues; the development of venous (congestive) infarctions of internal organs and the occurrence of trophic ulcers are possible (see full body of knowledge). With purulent thrombophlebitis, especially with sepsis, metastatic ulcers are found in the internal organs - lungs, kidneys, liver, brain, heart.

Clinical picture. Thrombophlebitis develops, as a rule, in the vessels of the lower extremities and pelvis; Thrombophlebitis of hemorrhoidal (rectal) veins is quite common (see full body of knowledge: Hemorrhoids). The main veins of the upper extremities are much less frequently affected; a typical manifestation of the disease is thrombophlebitis from tension, or Paget-Schretter syndrome (see full body of knowledge: Paget-Schretter syndrome). Thrombophlebitis of the veins of the pelvic organs, the portal vein and its branches and the venous system of the brain occurs, as a rule, as a result of acute or chronic inflammatory diseases of the relevant organs, as well as as a complication after surgery (see the full body of knowledge: Metrothrombophlebitis, Pylephlebitis, Thrombosis of the cerebral vessels brain).

With thrombophlebitis of the vessels of the lower extremities, the duration of the acute period is up to 20 days, subacute - from 21 to 30 days from the moment clinical signs of the disease appear. By this time, the processes of inflammation and thrombus formation usually end and the disease enters the stage of consequences of Thrombophlebitis, characterized by the presence of chronic venous insufficiency, and in the case of localization of the process on the lower extremities - the development of post-thrombophlebitic (post-phlebitic) syndrome, against which patients often experience relapses of Thrombophlebitis (recurrent Thrombophlebitis). The term chronic thrombophlebitis, previously used to refer to this condition, is not currently used.

Acute thrombophlebitis of the superficial (saphenous) veins usually develops on the lower extremity, most often affecting the varicose veins of the great saphenous vein of the leg (color figure 9). The process can be localized on the foot, lower leg, thigh or spread to the entire limb. Sharp pain suddenly appears along the thrombosed vein, and body temperature may rise to 38°. Upon examination, skin hyperemia and infiltration along the thrombosed vein are determined, which is palpated in the form of a dense, painful cord. The thrombotic process, ahead of inflammation of the vein, often spreads significantly above the clinically defined proximal limit of Thrombophlebitis. If occlusion of the main vein occurs, then the clinical picture of the disease consists of symptoms of acute superficial Thrombophlebitis and signs of its occlusion.

Rice. 9. Inflammatory infiltrates in the area of ​​varicose great saphenous vein of the right thigh with acute thrombophlebitis of the superficial veins. Rice. 10. External manifestations of thrombophlebitis of the deep veins of the left leg, complicated by gangrene of the left foot: the left leg is increased in volume (the perimeter of the thigh in the middle third is 53 centimeters; the perimeter of the shin in the middle third is 35.5 centimeters on the right - 37.5 centimeters and 25 centimeters, respectively) , the distal part and inner surface of the left foot are dark in color. Rice. 11. Microscopic specimen of the vein wall and surrounding tissues for thrombophlebitis caused by phlegmon: red thrombus in the lumen of the vein (indicated by an arrow), inflammatory infiltration of the vein wall and surrounding tissues; hematoxylin-eosin staining; ×80. Rice. 12. Microscopic specimen of the wall of the subclavian vein for endophlebitis associated with its catheterization: 1 - thrombotic masses; 2 - maturing granulation tissue at the site of the destroyed inner lining of the vein wall; hematoxylin-eosin staining; ×200.

Acute thrombophlebitis of the deep veins of the leg. Clinical picture of thrombophlebitis of the deep veins of the leg depends on the location and extent of the process, as well as on the number of vessels involved in the pathological process. The disease usually begins with pain in the calf muscles. As the process spreads, the pain sharply intensifies, a feeling of fullness appears in the lower leg, body temperature rises, sometimes with chills, and the general condition worsens. Moderate swelling appears in the distal part of the leg, which can increase and spread to its lower third. The skin has a normal color or a cyanotic tint; on the 2-3rd day a network of dilated superficial veins appears; The temperature of the skin of the lower leg is usually increased. When all deep veins of the leg and popliteal vein are affected, a sharp disturbance of venous outflow develops; Along with the described signs, diffuse cyanosis of the skin appears in the lower third of the leg and on the foot. With thrombophlebitis of the deep veins of the leg, one of the signs is Homans' symptom - the appearance or intensification of pain in the calf muscle when dorsiflexing, groaning. Palpation reveals pain in the lower leg muscles. A positive Moses symptom is determined: pain when squeezing the lower leg in the anteroposterior direction and its absence when squeezing from the sides. This symptom is important in the differential diagnosis of thrombophlebitis and myositis. A positive Lowenberg test is determined with a sphygmomanometer cuff placed on the middle third of the leg: sharp pain in the calf muscles appears at a pressure of 60-150 millimeters of mercury; Normally, minor pain occurs only at a pressure of 180 millimeters of mercury

Despite the large number of diagnostic techniques, recognizing acute thrombophlebitis of the deep veins of the leg is often difficult, since these techniques are not specific tests. The final diagnosis can be made using radioisotope and radiocontrast research methods.

Acute thrombophlebitis of the femoral vein. If thrombophlebitis develops in the femoral vein before the deep vein of the thigh flows into it, the venous outflow from the limb suffers less than when the overlying part is affected. Therefore, in clinical practice, at the suggestion of B. N. Kholtsov (1892), most surgeons usually divide the femoral vein into the superficial vein of the thigh, extending until the deep vein of the thigh flows into it, and the common femoral vein, located more proximally.

Primary thrombophlebitis of the superficial vein of the thigh, as well as thrombophlebitis that has spread from distally located veins, often occurs hidden due to well-developed collateral circulation. Patients note aching pain along the medial surface of the thigh; The most important clinical signs are dilation of the saphenous veins on the thigh in the basin of the great saphenous vein of the leg, slight swelling and pain along the vascular bundle on the thigh. Acute thrombophlebitis of the common femoral vein manifests itself with vivid clinical symptoms, since in this case most of the main collaterals of the thigh and lower leg are switched off from the blood circulation. The spread of the process from the superficial femoral vein to the common vein is characterized by sudden significant swelling of the entire lower limb, often with cyanosis of the skin. The general condition sharply worsens, body temperature rises, and chills occur at the same time. Severe swelling lasts for 2-3 days, after which it slowly decreases due to the inclusion of collateral vessels in the blood circulation. During this period, expansion of the saphenous veins is detected in the upper third of the thigh, in the pubic and groin areas. In primary acute thrombophlebitis of the common femoral vein, the disease begins acutely with pain in the upper third of the thigh and groin area. This is followed by swelling and diffuse cyanosis of the skin of the entire limb, severe pain in the upper third of the thigh, infiltration along the vascular bundle and a significant increase in inguinal lymph nodes. Otherwise, the clinical picture of the disease is similar to the clinical picture of ascending thrombophlebitis of the common femoral vein.

Acute thrombophlebitis of the main veins of the pelvis is the most severe form of thrombophlebitis of the lower extremities. Its typical manifestation is the so-called iliofemoral (iliofemoral) venous thrombosis, the development of which is divided into two stages: the stage of compensation (prodromal) and the stage of decompensation (pronounced clinical manifestations).

The stage of compensation corresponds to the initial occlusion of the common or external iliac veins with a parietal localization of the thrombus or with a small diameter thrombus, compensated by collateral circulation, in the absence of hemodynamic disturbances in the limb. The pathological process is sometimes limited to the first stage, and its only manifestation may be sudden thromboembolism of the pulmonary artery. With ascending thrombophlebitis, there is no prodromal stage, since the moment of occlusion of the iliac veins is preceded by a clinical picture of ascending thrombophlebitis of the main veins of the limb.

In the clinical compensation stage, the picture is poor. As a rule, a characteristic pain syndrome occurs - dull aching pain in the lumbosacral region, lower abdomen and lower limb on the affected side, caused by stretching of the walls of thrombosed veins, hypertension in distal venous segments and periphlebitis. Patients complain of malaise, lethargy; low-grade fever is possible. The duration of this stage is from 1 to 28 days, depending on the localization of primary thrombophlebitis, the speed of spread of the process and the compensatory capabilities of collateral circulation.

The stage of decompensation occurs with complete occlusion of the iliac veins, which leads to severe hemodynamic disorders in the limb. The pain intensifies sharply and is usually localized in the groin area, along the medial surface of the thigh and in the calf muscles. The swelling spreads to the entire limb to the inguinal fold, buttock, external genitalia and the anterior abdominal wall on the affected side. The color of the skin of the affected limb changes dramatically: it becomes either violet-cyanotic due to pronounced venous stagnation, or milky white due to severely impaired lymphatic drainage. After the swelling has decreased, an increased pattern of saphenous veins on the thigh and in the groin area is revealed, as well as signs of psoitis (pain in the iliac region with maximum hip flexion, flexion contracture in the hip joint), caused by periphlebitis of the common iliac vein, which is located in close proximity to the great lumbar muscles.

Complications. The course of acute thrombophlebitis of the main veins of the lower extremities and pelvis is often complicated by pulmonary embolism (see full body of knowledge). The most severe complications of Thrombophlebitis include venous gangrene (ischemic thrombophlebitis, gangrenous thrombophlebitis), in which thrombosis of the entire venous bed of the limb develops. The blood flow remains for some time, which leads to the accumulation of a large amount of fluid in the tissues of the limb and an increase in its volume by 2-3 times, then a spasm of the arteries occurs, a sharp disruption of arterial circulation, a putrefactive infection occurs (see full body of knowledge), a picture of septic shock develops (color figure 10). In some cases, purulent melting of the affected vessels occurs with the formation of superficial or deep abscesses, phlegmons and a sharp deterioration in the general condition due to intoxication of the body.

Patients with unrestored blood flow in the main veins and decompensation of collateral circulation subsequently suffer from postthrombotic disease (postthrombophlebitic syndrome) - chronic venous insufficiency of the lower extremities, which developed after suffering acute thrombophlebitis. The cause of postthrombophlebitis syndrome is blockage of the main veins by a thrombus or, more often, impaired patency of the recanalized veins, in which as a result of thrombophlebitis, the venous valves were destroyed, as well as the presence of compressive paravasal fibrosis. Most often, postthrombophlebitis syndrome develops after thrombophlebitis of the iliofemoral or femoropopliteal sections of the deep vein of the thigh. Often recanalization of one segment of the vein is combined with blockage of another. Of particular importance is the incompetence of the valves of the perforating veins connecting the saphenous veins of the limb with the deep ones. In this case, there is a reflux (see full body of knowledge) of blood from the deep veins into the subcutaneous veins, leading to secondary varicose veins of the saphenous veins. Violations of venous hemodynamics in postthrombophlebitic syndrome are reduced to dysfunction of the muscular-venous pump; this is accompanied by venous stasis, which is accompanied by secondary lymphostasis, and then functional and morphological changes in the skin, subcutaneous tissue and other tissues of the limb. A sharp increase in venous pressure leads to pathological shunting of blood flow through arteriolo-venular anastomoses and emptying of capillaries, accompanied by tissue ischemia.

Characteristic symptoms of postthrombophlebitis syndrome are bursting pain and a feeling of heaviness in the lower leg, swelling of the foot and lower leg, varicose veins of the limb, and sometimes of the anterior abdominal wall. In the stage of decompensation, pigmentation and induration of the skin and subcutaneous tissue appear in the lower third of the leg, often along its medial surface. The skin is thinned, motionless (does not fold), devoid of hair; after a minor injury, scratching, or for no apparent reason, a trophic ulcer often forms (see full body of knowledge), at first small, healing after treatment, and then recurrent, increasing in size.

Diagnosis. To make a diagnosis of acute thrombophlebitis of the main veins, in addition to clinical signs, distal phlebography (see full body of knowledge), antegrade and retrograde iliocavography (see full body of knowledge: Cavography), as well as a study with labeled fibrinogen are of great importance. These studies make it possible to determine the localization and extent of venous occlusion, identify embologenic forms of the disease, and determine the activity of the thrombotic process. An indirect assessment of thrombus formation activity can be made by analyzing the state of the hemostatic system. The most informative tests are thromboelastography (see full body of knowledge), determination of the time of thrombus formation according to Chandler, plasma tolerance to heparin (see), fibrinogen concentration (see full body of knowledge), intensity of spontaneous lysis of a blood clot (see full body of knowledge: Blood clot) , antiplasmin activity of plasma (see full body of knowledge: Fibrinolysin), aggregation ability of platelets and erythrocytes. The thrombotic state of the hemostatic system, revealed by analyzing these indicators, confirms the diagnosis.

Diagnosis of acute superficial thrombophlebitis usually does not present any particular difficulties. However, when thrombophlebitis spreads to the saphenofemoral anastomosis, that is, to the point where the great saphenous vein of the leg flows into the femoral vein, and there are clinical signs of damage to the deep veins of the limb, it is necessary to perform an X-ray contrast study. The most dangerous forms of the disease, such as segmental occlusion of a venous line over a short distance or a floating, that is, mobile, thrombus that is freely located in the blood stream and has a single point of fixation at the base, can only be detected using a radiocontrast examination method.

Radiation diagnostic methods for thrombophlebitis include angiogramraphy, thermography and radionuclide (radioisotope) study. The most important place among them is venography. It allows not only to identify the localization of blood clots and their extent, but also to assess the state of collateral circulation and anastomoses between deep and superficial veins in various stages of thrombophlebitis development. When interpreting a venogram, special attention is paid to the presence or absence of contrasting of the main veins, filling defects in them, amputation of the main veins at various levels. The phlebographic picture of venous obstruction is very diverse and largely depends on the factors that caused these changes. In this regard, difficulties often arise when interpreting a venogram. Thus, a filling defect on a venogram, which is one of the direct signs of thrombosis, can be due to a tumor, an inflammatory process, an enlarged lymph node, or the presence of intravascular organic formations (congenital and acquired septa). In these cases, differential diagnosis is extremely difficult and requires taking into account the entire range of clinical, laboratory and instrumental examination methods.

It is advisable to use radionuclide diagnostic methods (see the full body of knowledge: Radioisotope diagnostics) in cases of suspected deep vein thrombosis. Radiopharmaceuticals are injected into the vascular bed - human serum albumin labeled with radioactive iodine (131 I), technetium pertechnetate (99m Tc) or inert radioactive gas xenon (133 Xe), dissolved in an isotonic solution of sodium chloride, and others. The technique with administration of radiopharmaceuticals that selectively accumulate in the thrombus, for example, fibrinogen labeled 123 I, 125I, 131 I (see full body of knowledge: Radiopharmaceuticals).

To measure radioactivity at selected points on the shin or thigh, you can use any radiometric single-channel setup with a well-collimated detector (see the full body of knowledge: Radioisotope diagnostic instruments).

A study carried out using a gamma camera using the same radiopharmaceuticals allows not only to trace their passage through the vessels, but also to obtain an image of this process on the screen. Such radionuclide venography using 99m Tc was proposed and developed by L. Rosenthal in 1966. Subsequently, M. M. Webber et al. (1969), Rosenthal and Grayson in 1970 proposed for the same purposes albumin macroaggregate labeled with 99m Tc or 131 I. The use of the latter compound is especially indicated in patients with suspected pulmonary embolism, when it is advisable to simultaneously perform radionuclide venography and lung scintigraphy.

The research procedure is relatively simple. 99m Tc or 131 I labeled micro or macroaggregates of albumin are injected into the dorsal vein of the foot. Subsequent serial scintigraphy (see full body of knowledge) or radiometry (see full body of knowledge) allows you to observe the passage of the drug through the deep veins of the limb along their entire length, as well as assess the state of collateral venous circulation. The undoubted advantage of this technique is that results can be obtained within 30 minutes from the start of the study.

Thermographic research (see full body of knowledge: Thermography) for thrombophlebitis and other lesions of the vascular system is based on recording natural infrared radiation. Thermography is most widely used in studies of the lower extremities with various lesions of the veins and arteries (Figure). During thermography, attention is paid to the symmetry of temperature in both extremities, the presence of foci of hypo and hyperthermia, and the absolute and relative temperature is measured in different parts of the area under study. With varicose veins, accompanied by chronic venous insufficiency, a branched network of superficial vessels appears, the temperature above which is significantly higher than the temperature of the surrounding tissues. With thrombosis of a large venous trunk, a diffuse increase in temperature below the level of the lesion is noted. The diagnostic capabilities of thermography in recognizing occlusive lesions of the vessels of the lower extremities exceed the clinical capabilities of examining such patients, especially in the early stages of the process, and significantly complement the results of other methods of radiation diagnostics.

Diagnosis of postthrombophlebitis syndrome is based on anamnesis (past acute venous, often iliofemoral thrombosis), clinical examinations of the patient and functional tests (see full body of knowledge: Varicose veins). Clarification of the localization and nature of the violation of the patency of the main veins, the state of the valve apparatus of the perforating veins and the presence of blood reflux from deep veins to the superficial ones is established using phlebography, phlebotonometry (see full body of knowledge) and other techniques.

Differential diagnosis. Acute superficial thrombophlebitis must be differentiated from acute lymphangitis (see full body of knowledge). With the latter, the red stripes of skin hyperemia are narrower and more delicate, and cord-like infiltrates along their course are absent or very thin and unnoticeable. Acute thrombophlebitis of the deep veins of the lower extremities and pelvis is usually differentiated from diseases in which edema of the lower extremities occurs: with erysipelas (see full body of knowledge) and lymphostasis (see full body of knowledge), intermuscular hematoma (see full body of knowledge), deep phlegmon (see full body of knowledge) with myositis (see full body of knowledge), edema of the lower extremities with heart failure (see full body of knowledge) or after injuries, lumbosacral radiculitis (see full body of knowledge) with neuritis of the femoral nerve, tumors (see full body of knowledge ) or inflammatory infiltrates, compressing the main veins. With all these diseases, there is usually no cyanosis of the skin and dilatation of the superficial veins on the affected limb. With lymphostasis and heart failure, there is no pain along the vascular bundle. With deep phlegmon of the thigh, there is a deterioration in the general condition, symptoms of intoxication, an increase in body temperature to 39-40°, severe pain not only in the projection of the vascular bundle, but also in other areas, and edema (without cyanosis) is limited to the thigh area; in addition, it is possible to detect the entrance gates of infection (abrasions, injection sites, etc.). With erysipelas, the disease begins with chills and high body temperature (up to 40°); On the skin of the affected limb, bright hyperemia with a clear border is determined. With lumbosacral radiculitis with neuritis of the femoral nerve, there are characteristic neurological symptoms that are not characteristic of Thrombophlebitis. When diagnosing acute Thrombophlebitis, acute thrombosis, embolism of the main arteries should be excluded (disappearance of peripheral vascular pulsation, symptoms of acute ischemia, late-appearing edema of the limb, absence of a prodromal stage of the disease) .

Postthrombophlebitis syndrome is differentiated from venous malformations, compression of the inferior vena cava or iliac vein by a tumor, as well as chronic disorders of lymphatic drainage (see full body of knowledge: Elephantiasis). For this purpose, phlebography or lymphography is performed (see full body of knowledge).

Treatment. Patients with acute limited thrombophlebitis of the superficial veins of the leg and thrombophlebitis of the veins of the upper extremities are treated on an outpatient basis. Patients with thrombophlebitis of the main deep veins should be referred to a surgical hospital, preferably to specialized vascular surgical departments. Patients with purulent and septic thrombophlebitis should be hospitalized in purulent surgical departments.

Treatment of Thrombophlebitis is aimed at eliminating the inflammatory process and stopping the thrombotic process, restoring the patency of thrombosed veins, eliminating hemodynamic disturbances in the affected limb, and preventing complications.

All patients with thrombophlebitis, in the absence of a threat of embolism, maintain an active regimen; An elevated position of the affected limb is recommended. To reduce inflammatory phenomena, cold is applied locally, acetylsalicylic acid (aspirin), butadione, reopirin, brufen, venoruton (troxevasin) and others are prescribed internally. For thrombophlebitis of the superficial veins, dressings with heparin, butadione or venoruton ointment, electrophoresis of heparin and chymopsin are used locally. To improve hemodynamics in the affected limb, the leg is bandaged with elastic bandages. For thrombophlebitis associated with infection, antibiotics and sulfonamide drugs are prescribed. Starting from the 10-12th day after the onset of clinical signs of the disease (with conservative treatment), as well as in the postoperative period, it is advisable to use magnetic therapy (see full body of knowledge), diadynamic currents (see full body of knowledge: Pulse currents) or chymopsin electrophoresis.

Methods of conservative treatment of acute thrombophlebitis of the main veins also include antithrombotic therapy aimed at stopping the thrombotic process. As an independent method, it is used for common occlusive (non-embologenic) forms of Thrombophlebitis, when radical treatment is not indicated or is impossible. Since active thrombus formation in the main veins is caused by the thrombotic state of the hemostatic system, the main pathogenetic principle of antithrombotic therapy is the simultaneous elimination of hypercoagulation, inhibition of fibrinolysis and increased aggregation of blood cells through the complex use of anticoagulants, antiplatelet agents and fibrinolysis activators. The optimal method of such treatment is continuous intravenous infusion (for 3-5 days) of heparin (450-500 units/kg per day), rheopolyglucin (0.7-1.0 grams/kg per day), nicotinic acid (2.0 -2.5 milligrams/kilogram per day) and trental (3-5 milligrams/kilogram per day). Then rheopolyglucin is discontinued, and the remaining drugs continue to be administered in fractional doses until the 20-21st day from the moment clinical signs of thrombophlebitis appear. The use of heparin is contraindicated in venous gangrene due to an increase in edema caused by increased permeability of the vascular wall, and as a result, the risk of compression of the main arteries, nerve trunks and worsening tissue ischemia. Complex antithrombotic and anti-inflammatory therapy significantly improves microcirculation and helps eliminate hemodynamic disorders in the affected limb.

The effectiveness of thrombolytic therapy for acute thrombophlebitis of the main veins with fibrinolysis activators (streptase, urokinase and others) is limited in cases of widespread thrombosis with total occlusion of the venous lines due to the difficulty of contact of fibrinolysis activators with the thrombus, in the descending form of iliofemoral thrombosis and Paget-Schretter disease. Thrombolytic therapy is contraindicated in embologenic thrombosis due to the risk of thrombus fragmentation and pulmonary embolism.

Therapeutic exercise helps to reduce physical inactivity that occurs during prolonged bed rest in patients with thrombophlebitis, improves venous outflow, and in connection with this prevents relapses of thrombosis. Early activation of patients is indicated mainly for acute thrombophlebitis of the veins of the lower and upper extremities (thigh, lower leg, subclavian and axillary veins). Therapeutic exercise is contraindicated in patients with acute thrombosis of the main veins of the pelvis and inferior vena cava before removal of the thrombus or its organization, as well as in patients with thromboembolic complications of the venous system.

The timing of activation of patients with thrombophlebitis depends mainly on the severity of the disease. For thrombophlebitis of the saphenous veins, physical therapy is prescribed from the 2-3rd day, deep - from the 5-10th day, when the local inflammatory reaction decreases, body temperature decreases and pain stops. In patients with thrombophlebitis of the lower extremities, physical therapy begins with exercises for the healthy leg, arms and breathing exercises while maintaining an elevated position of the diseased leg. Classes are carried out 1-2 times a day, the duration of the lesson is 7-10 minutes. After 1-3 days, exercises are prescribed for the sore leg: a short-term change from an elevated position to a horizontal one, slow flexion and extension of the foot. Gradually increase the range of movements in the affected leg, the number of exercises for the limbs and torso with the patient lying on his back, on his side; increase the degree of effort of the muscles of the foot, lower leg, thigh of the sore leg; include short-term sitting with legs horizontal and with legs down; gradually move on to standing up and measured walking with preliminary bandaging of the leg with an elastic bandage. Jerk exercises, squats, and jumps are excluded. It is advisable to repeat movements in the ankle joints many times during the day with the force of the calf muscles to improve the pumping function of the muscles and the development of collaterals.

Spa treatment using hydrogen sulfide or radon baths (see full body of knowledge) is carried out in cardiovascular sanatoriums for patients who have suffered thrombophlebitis of the main veins, during the cool season (spring or autumn), no earlier than 3-4 months after the acute phenomena have subsided diseases.

In acute thrombophlebitis of the great saphenous vein of the leg with a clinically detectable upper border in the middle or lower third of the thigh and no signs of thrombosis spreading to the deep veins, an emergency operation is indicated - ligation of the vein at its junction with the common femoral vein with revision of the saphenofemoral anastomosis (see full body of knowledge: Ligation blood vessels). The presence of continued thrombosis of the femoral-iliac venous segment dictates the need to perform thrombectomy during this operation (see full body of knowledge) through the mouth of the great saphenous vein of the leg. If the lesion of the latter is limited to the lower third of the thigh, surgery can be performed in a delayed manner after clarifying the upper limit using local radiometry with labeled fibrinogen.

In the postoperative period, complex antithrombotic therapy is indicated, the same as with conservative treatment. From the first day after surgery, physical therapy is prescribed to prevent thromboembolic complications.

Surgical treatment is absolutely indicated for embologenic forms of the disease, primarily for the purpose of preventing pulmonary embolism.

Radical surgical interventions include thrombectomy, which, depending on the location of the embolus, is performed through the femoral, retroperitoneal, laparotomy or combined approaches. After thrombectomy from the main vein, it is advisable to apply a temporary arteriovenous fistula to improve hemodynamics.

Complete restoration of blood flow in the affected vessels is possible with a floating thrombus in the external and common iliac veins, emanating from the internal iliac vein, as well as with saphenofemoral thrombosis spreading into the iliac venous segment. In this case, thrombectomy can be performed through the internal iliac or great saphenous vein of the leg.

Widespread occlusion of the deep veins of the leg in combination with damage to the overlying venous segments, as a rule, excludes the possibility of complete restoration of blood flow and is fraught with the risk of recurrent thrombosis in the postoperative period.

Palliative interventions are indicated when radical surgery is technically impossible or contraindicated due to the severity of the patient’s general condition. These include partial occlusion of the main veins using the plication method using a mechanical suture or special clamps, as well as implantation of an intravenous filter, which allows the formation of several small-diameter channels in the lumen of the main vein, preventing massive thromboembolism of the pulmonary artery. Plication can be performed as an independent intervention or in combination with thrombectomy, if complete restoration of blood flow was impossible, loose thrombotic masses that were not removed remained in the vessel, or ascending phlebitis of the main vein was detected during the operation. The filter is implanted retrograde (through the internal jugular vein) or antegrade (through the great saphenous vein of the leg or the femoral vein of a healthy limb). Implantation of an intravenous filter provides reliable prevention of pulmonary embolism; in addition, it is less traumatic than plication of the great veins. Ligation of the main veins for the purpose of preventing pulmonary embolism can be performed only in exceptional cases when other interventions are impossible. This operation (especially ligation of the iliac veins) subsequently leads to the development of severe postthrombophlebitis syndrome (see full body of knowledge: above). In addition, it does not exclude the possibility of ascending thrombosis in the presence of severe phlebitis in the dressing area.

Treatment of complications of thrombophlebitis. With purulent thrombophlebitis, it is usually limited to opening and draining the abscess. The occurrence of venous gangrene (see full body of knowledge) with an increase in ischemic disorders and the appearance of severe intoxication serves as an indication for amputation (see full body of knowledge) of a limb. However, many cases of incipient venous gangrene can be treated conservatively - complex antithrombotic (without the use of heparin), detoxification and antibacterial therapy. Treatment of pulmonary embolism - see, complete body of knowledge: Pulmonary embolism.

Treatment of postthrombophlebitis syndrome can be conservative, surgical and combined. Conservative treatment is used when the course of the disease is favorable and there are contraindications to surgery. It includes: compression of the affected limb with an elastic bandage or medical stocking; limitation of static loads, exclusion of heavy lifting and forced loads (running, jumping), elevated position of the legs when resting; training walking with a slow increase in loads, therapeutic swimming; repeated (once every 5-6 months) courses of drug therapy using drugs that reduce the aggregation of blood cells and improve microcirculation - trental, theonicol (complamin), normalizing the catabolism of lipids and proteins (linetol, miscleron), metabolic processes and permeability vascular wall (venoruton, glivenol, aescusan, ascorutin), as well as anti-inflammatory (acetylsalicylic acid, butadione, reopirin, brufen) and antihistamines (suprastin and others); repeated (simultaneously with drug treatment) courses of physiotherapy - magnetic field (see full body of knowledge: Magnetotherapy), diadynamic currents, chymopsin electrophoresis (see full body of knowledge: Electrophoresis).

Surgical treatment of postthrombophlebitis syndrome aims to improve venous hemodynamics in the limb. According to V.S. Savelyev and G.D. Konstantinova (1980), the most widely used operation is to separate the deep and saphenous veins by subfascial ligation of the perforating veins of the leg in combination with the removal of varicose saphenous veins. Operations are also used to create additional pathways for the outflow of venous blood from the limb, for example, cross autovenous shunting according to Palma-Esperon for occlusions of the iliac and proximal femoral vein and others. Of the numerous operations aimed at the formation of valve mechanisms in the main veins, extravasal valve correction deserves attention Vvedensky spiral. The best effect can be obtained by combining various methods, including combined reconstructive operations on veins and lymphatic vessels.

Forecast. In patients with thrombophlebitis of the superficial veins, after the elimination of inflammation, the ability to work is preserved. In patients with completely restored blood flow in the main veins, as well as those operated on for uncomplicated superficial thrombophlebitis, the prognosis is usually favorable: they recover and after 1-2 months return to their previous work activity. A less favorable prognosis for patients with unrestored venous blood flow; they develop chronic venous insufficiency with severe swelling-pain syndrome, trophic ulcers, and therefore permanent loss of ability to work occurs.

Prevention of acute thrombophlebitis should be carried out taking into account the potential etiological factor. Patients with varicose veins are recommended to regularly bandage the lower extremities with an elastic bandage or wear special elastic stockings. These measures are also indicated for women in the second half of pregnancy, when the enlarged uterus compresses the veins of the pelvis, which leads to slower blood flow in the lower extremities. Measures to prevent thrombophlebitis in the postoperative period include early activation of patients, the use of physical therapy, and massage. To prevent thrombophlebitis, strict adherence to asepsis and antisepsis during intravenous infusions is necessary, especially in cases of long-term catheterization for the purpose of constant administration of medicinal solutions. For intravenous infusions lasting more than 3 days, catheterization of the subclavian or femoral veins is advisable; in this case, small doses of heparin are added to the solutions (or injected into the catheter between injections). If necessary, they resort to improving the rheological properties of blood using hemodilution, the introduction of solutions with anti-aggregation properties (low molecular weight polyvinylpyrrolidone preparations, rheopolyglucin and others). When preventing thrombophlebitis, special attention is paid to people over 40 years of age.

Prevention of postthrombophlebitis syndrome consists of timely and complete treatment of acute venous thrombosis.

Wandering allergic thrombophlebitis (synonyms: allergic wandering phlebitis, migratory thrombophlebitis) is a type of systemic hyperergic vasculitis (see full body of knowledge: Vasculitis), characterized by segmental inflammatory lesions of the superficial subcutaneous, and sometimes simultaneously deep veins of the lower extremities. The process may also involve the veins of the upper extremities and torso; at the same time, thrombophlebitis of the venous vessels migrates, appearing in one place or another.

The etiology of wandering allergic thrombophlebitis has not been fully elucidated. It usually complicates the course of other diseases, in particular malignant tumors, tuberculosis, influenza, and chronic focal infections. With great consistency, this type of vasculitis is detected in thromboangiitis obliterans (see.

Obliterating lesions of the vessels of the extremities). Occasionally it is combined with rheumatoid arthritis (see full body of knowledge), periarteritis nodosa (see full body of knowledge: Periarteritis nodosa), Wegener's granulomatosis (see full body of knowledge: Wegener's granulomatosis), hemorrhagic vasculitis (see full body of knowledge: Schönlein-Henoch disease) , Chiari disease (see full body of knowledge: Chiari disease). Inflammation of the veins and their thrombosis in this disease are associated with damage to the structures of the inner lining of blood vessels by immune complexes or sensitized immunocompetent cells. The antigenic stimulus remains unclear. At the same time, there is reason to believe that it is a protein of the tissue components of the vascular wall itself, subject to change under the influence of endogenous or exogenous pathogenic factors (see the full body of knowledge: Autoantigens). The autoimmune mechanism for the development of such thrombophlebitis is confirmed by experimental data.

Wandering allergic thrombophlebitis is observed mainly in men. The disease, as a rule, begins acutely and is characterized by the appearance of painful nodules along the superficial veins of the extremities with redness of the skin over them, and sometimes an increase in temperature. The disease lasts a long time (up to 3-4 years) with remissions and relapses. The diagnosis of the disease is made on the basis of the migratory nature of the lesion of the superficial veins with the formation of painful nodules along their course. Histological examination of a thrombosed vein using the immunofluorescence method (see full body of knowledge: Immunofluorescence) allows us to establish the immunopathological genesis of phlebitis.

The greatest effect in the treatment of the disease is observed with the use of cytostatics (see full body of knowledge: Antitumor agents), corticosteroid hormones (see full body of knowledge: Corticosteroids) and hyposensitizing agents (see full body of knowledge: Desensitizing agents). In some cases, anticoagulants are recommended. Sometimes they resort to surgical treatment methods.

Thrombocythemia ⇒

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Thrombophlebitis - symptoms and treatment

What is thrombophlebitis? We will discuss the causes, diagnosis and treatment methods in the article by Dr. A. G. Khitaryan, a phlebologist with 35 years of experience.

Definition of disease. Causes of the disease

Thrombophlebitis- a disease of the circulatory system, characterized by damage to the internal tissues of the vein wall with the development of a local inflammatory reaction, accompanied by rapid adhesion (clumping) of platelets at the site of the lesion.

Reasons for the development of this disease:

• varicose veins - according to statistics, 60% of patients with varicose veins develop thrombophlebitis over time;
• An important role in identifying the cause of thrombosis, especially spontaneous, in young people is played by genetic testing for thrombophilia - deficiency of the prothrombin complex factor protein S, deficiency of the anticoagulant protein C, deficiency of antithrombin III (hereinafter referred to as AT III), mutation of coagulation factor V (Leiden mutation).
• high estrogen levels - pregnancy;
• hormone replacement therapy;
• Long-term use of oral contraceptives can also become a trigger for blood clots.

There are a number of other factors influencing the development of this disease:

• smoking;
• associated thrombocytopenia (decreased heparin synthesis in the liver);
• impaired synthesis of platelet-derived growth factor in the bone marrow;
• fungal and bacterial infections;
• autoimmune antiphospholipid syndrome;
• excess body weight;
• malignant neoplasms (especially tumors of the pancreas, lungs, stomach);
• advanced age of the patient;
• long-term immobilization;
• the use of certain medications (in particular, cytostatics);
• presence of venous thromboembolic complications in the anamnesis.

The incidence of thrombophlebitis depends on many factors. There is a significant difference between age categories. Every year, the debut of thrombophlebitis is registered in 0.3 - 0.6 per 1000 people under the age of 30 years and in 1.2 - 1.8 per 1000 elderly patients.

Differences are also recorded by gender. Thus, in men, thrombophlebitis develops on average in 0.05 - 1.4 per 1000 people. For women, this figure is much higher - from 0.31 to 2.2 per 1000 people.

Recent studies confirm the importance of genetically determined thrombophilia in the development of thrombophlebitis, especially in patients without previous trauma to the vascular wall. Thrombophilia is a pathology characterized by a predisposition to the formation of vascular thrombosis of various locations, prone to relapse. The cause of this disease is the presence of a defect in the blood coagulation system, as well as a genetic or acquired pathology of blood cells. Clinical manifestations of thrombophilia are multiple thromboses of various locations, which are accompanied by swelling and pain in the legs, cyanosis of the skin and pulmonary embolism. Repeated occurrence of recurrent thrombosis in the patient's history may indicate the presence of thrombophilia, which can be confirmed by laboratory tests. The choice of further therapy for thrombophilia directly depends on its type. Thrombolytics, anticoagulants and antiplatelet agents are usually used.

The Leiden mutation is found in 23% of patients. Mutations of prothrombin, AT III, heparin cofactor, and protein C and S systems are also significant. There is also a wide variation in the incidence of thrombophlebitis based on the location of occurrence of thrombophlebitis. In 65–80% of cases, the system of the great saphenous vein is affected, in 10–20% of cases the system of the small saphenous vein occurs, while the bilateral variant of thrombophlebitis occurs only in 5–10% of cases.

One of the most significant factors in the development of thrombophlebitis is the presence of varicose veins. Up to 62% of patients with thrombophlebitis have this pathology. Post-traumatic thrombophlebitis develops after intravenous administration of various drugs, as well as in the case of vein catheterization.

If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of thrombophlebitis

The location, prevalence and timing of development of the pathological process, as well as the etiological factor are the reasons that determine the clinical manifestations of thrombophlebitis.

With the development of thrombophlebitis against the background of varicose veins, the superficial veins of the lower extremities are most often affected, especially the trunk and tributaries of the great saphenous vein.

When the vessels of the lower extremities are damaged, dense cords of purple color form in the projection of the affected vessels, the symptoms of which include pronounced hyperemia and arbitrary soreness or pain on palpation.

With pronounced inflammation of the superficial veins on the adjacent skin, symptoms such as redness, soreness, fever and swelling appear. Thrombophlebitis can spread to the deep vein system. The most dangerous localization for the development of this complication is the primary location of the pathological process near the sapheno-femoral and sapheno-popliteal anastomosis, as well as the perforating veins of the popliteal region. It is important to note that deep venous trunks and numerous collaterals are the main causes of mild symptoms of thrombophlebitis of the deep veins of the leg.

When lowering your legs down, a bursting pain appears in the calf muscles. This pathology is also characterized by the development of edema of the distal parts of the limb, gradually spreading higher up the leg. It is even possible to expand the network of superficial veins of the leg, thigh and anterior abdominal wall. The femoropopliteal venous segment will appear more pronounced due to the presence of severe deviations in the functioning of the outflow system and the complexity of the blood flow compensation process.

Acute thrombophlebitis poses the greatest threat, as it can cause serious disturbances in the blood supply to the limb and thromboembolic complications that are life-threatening. Thus, patients develop intense swelling of the limb with characteristic acute pain. In the future, this swelling can be localized in the inguinal-scrotal region, in the buttocks and the anterior abdominal wall. Symptoms of thrombosis of the inferior vena cava are expressed by the intensity of swelling of the lower half of the body and both lower extremities. Also characteristic signs of this type of thrombosis are dilation of the veins of the anterior abdominal wall and thrombosis of the hepatic and renal veins, which ultimately determine the clinical picture and its outcomes.

The vein of the upper limb is characterized by post-traumatic thrombophlebitis, which occurs as a result of intravenous injections, as well as catheterization of the vein, damaging the endothelium. The most typical lesion is in the area of ​​the cubital fossa. Clinically manifested by pain, hardness, redness and swelling along the affected vein. Spread to the deep venous and pulmonary artery systems almost never occurs.

Thrombophlebitis after endovascular treatment of varicose veins is rare, occurring in only 0.1 - 1.2% of all cases of complications of this treatment method. The highest frequency is typical for sclerotherapy. Prevention of this complication is achieved by immediate mobilization of the patient after manipulation and the use of low molecular weight heparins in prophylactic doses.

Pathogenesis of thrombophlebitis

Thrombosis is an adaptive reaction of the body, during which the production of blood clotting factors occurs, aimed at the formation of a blood clot and stopping bleeding. If the inner wall of the vessel is damaged or disrupted, a local inflammatory reaction develops. A leukocyte and then a platelet clot attaches to the damaged area, which enhances the inflammatory reaction and often leads to thrombosis of the lumen of the vessel. Thrombophlebitis is associated with the components of the so-called “Virchow triad”:

1. damage to the vascular intima caused by trauma or inflammation;
2. change in coagulability;
3. decrease in the speed of venous blood flow - manifests itself as a result of varicose veins, obesity, decreased physical activity, immobilization, etc.

It follows that a pathological change in the endothelium of the veins, which is the leading trigger for the formation of thrombophlebitis, leads to a violation of the dynamic balance of the hemostasis system. Recently, international consensus has accepted the equality between the terms “acute thrombophlebitis” and “thrombosis of superficial veins”, which determines the commonality of pathogenetic mechanisms, complications and treatment tactics.

Complications of thrombophlebitis

Complications of thrombophlebitis can be life-threatening! The danger is the spread of a blood clot from the superficial veins to the deep ones and the migration of thrombotic masses into the small branches of the pulmonary artery with the subsequent development of pulmonary embolism (hereinafter referred to as PE). Mainly, the veins of the lower extremities act as a source of thrombus formation in pulmonary embolism.

In some cases, the sources are the veins of the upper extremities and the right side of the heart. Pregnant women and women who have taken oral contraceptives for a long time for a certain period of time, as well as patients with thrombophilia, are at risk of developing the disease. There is a possibility of the process spreading to the veins of the pelvis and abdominal cavity with the subsequent occurrence of ischemia of the affected limb and possible septic complications.

Diagnosis of thrombophlebitis

If there is a suspicion of the development of thromboembolism of the branches of the pulmonary artery, it is indicated spiral computed tomography(SCT) of the chest organs, which helps to identify even the most minor changes in the area under study.

Angiopulmonography- a technique that allows you to examine the branches of the pulmonary artery after administration of a contrast agent. Mandatory performing an ultrasound with an unclear clinical picture, suspicion of deep vein thrombophlebitis, pregnant women, with thrombophlebitis localized on the thigh or the upper third of the back surface of the leg. Ultrasound diagnostics is performed in combination with dopplerography, which allows you to determine the speed characteristics of the flow. Important in the diagnosis of thrombophlebitis is the determination of the carriage of genetic polymorphisms in the coagulation gene system, the most significant are mutations of protein S, deficiency of the anticoagulant protein C, deficiency of AT III, mutation of coagulation factor V (Leiden mutation). The examination begins with inspection, palpation and diagnostic tests. Blood is drawn for laboratory diagnostics (coagulogram). This study allows us to identify violations of the coagulation system. The blood D-dimer level is determined; this indicator indicates thrombus formation in the human body. It must be remembered that the level of D-dimer is not a criterion for the severity of the process.

Treatment of thrombophlebitis

Thrombophlebitis is a disease that can threaten the patient’s life and therefore requires immediate treatment.

Therapeutic and preventive measures for thrombophlebitis are complex and can be conservative and surgical. The main objectives are to maximize the elimination of risk factors, reduce and alleviate local symptoms, prevent the spread of thrombophlebitis to the deep vein network and prevent venous thromboembolic complications.

Surgical treatment

Not long ago, the gold standard for the treatment of ascending thrombophlebitis was crossectomy (Troyanov-Trendelenburg operation), but practice results have shown that this method of surgical intervention is the most traumatic and life-threatening for patients.

According to the latest revised clinical guidelines, endovenous laser coagulation (EVLC) is a low-traumatic and safe technique for ascending thrombophlebitis. This method can be used to operate on any category of patients. As a rule, surgery is performed under local tumescent anesthesia. When the process goes beyond the sapheno-femoral or sapheno-popliteal anastomosis, thrombectomy is performed from the main veins. Surgery can be performed using regional anesthesia or intubation endotracheal anesthesia. The preference for thrombectomy method depends on the level of location of the proximal part of the thrombus.

In case of perforator thrombosis, thrombectomy from the perforator vein is performed. In case of embolic thrombosis of the femoropopliteal segment, ligation of the superficial femoral vein (SFE) is indicated.

In case of embolic-dangerous iliocaval thrombosis, plication of the inferior vena cava is performed.

The figure shows the implantation of a vena cava filter into the inferior vena cava, the indication for which is embolic iliocaval thrombosis.

Conservative treatment

Today, for existing indications, the most effective method will be anticoagulant therapy. In medical practice, it is customary to distinguish between direct-acting anticoagulants, which help reduce thrombin activity in the blood, and indirect-acting anticoagulants, which prevent the formation of prothrombin in the liver. Low molecular weight heparins belong to the group of direct-acting anticoagulants. These include medications such as Enoxaparin sodium (Anfibra, Clexane, Hemapaxan, Lovenox), Dalteparin (Fragmina) or Tinzaparin, which must be administered subcutaneously 1-2 times during the day. The use of low molecular weight heparins results in maximum effectiveness and minimal side effects. Indirect anticoagulants are Warfarin derivatives, which require special caution and a high degree of laboratory control (INR). Currently, the greatest interest is in drugs that do not require laboratory monitoring of INR and with lower risks of complications, for example, such as Xarelto (Rivaroxaban) or Pradaxa.

In addition, the patient is prescribed long-term wearing of compression hosiery and auxiliary pharmacotherapy, phlebotonic drugs (Detralex; Venarus; Phlebodia 600), etc. It is also advisable to prescribe non-steroidal anti-inflammatory drugs and local treatment.

Forecast. Prevention

In the early period after thrombosis (no later than 72 hours), in some cases, drugs that dissolve the blood clot (thrombolytics) are used to restore vessel patency.

It is important to wear compression stockings. Compression hosiery is a medical product and is selected individually for each patient. It is prescribed before surgical interventions to patients suffering from varicose veins, obesity, pregnant women, long flights, moving, etc.

Intermittent pneumocompression is a physiotherapeutic method of massaging tissue using special multi-chamber cuffs with different operating pressures. This technique has excellent lymphatic drainage properties and helps reduce swelling.

Electromyostimulation using the VENOPLUS device - this patented technique consists in the fact that electromyostimulation leads to muscle contraction and activation of the muscle-venous pump.

Acute superficial thrombophlebitis. This form thrombophlebitis. as a rule, does not present difficulties for diagnosis. Patients complain of pain, painful lumps along the veins. The pain intensifies when walking, active and passive movements. Varicose veins of the thigh and leg are most often affected. The body temperature rises, upon examination of the limb, dense infiltrates are determined along the vein, painful on palpation. The skin is hyperemic and swollen. When intact veins are affected, especially in obese patients, a painful cord-like compaction is felt.

Treatment. Conservative therapy in the acute period at high body temperature includes rest with the leg elevated, anti-inflammatory and anticoagulant therapy (acetylsalicylic acid, butadiene, reopirin, venoruton, troxevasin; dressings with heparin, venoruton ointments, novocaine blockade with heparin), physiotherapeutic procedures (UHF , electrophoresis of trypsin, potassium iodide, Sollux); moderate walking with a limb bandaged with an elastic bandage.

Indications for surgery (absolute and relative) are the localization of thrombosis in the area of ​​the mouth of the saphenous veins (the threat of the process transferring to the deep veins and thromboembolism); purulent thrombophlebitis (threat of sepsis). The thrombosed vein is excised or its mouth is ligated when it flows into a deep vein.

Chapter 5. Acute thrombophlebitis.

What is thrombophlebitis?

How can I tell if I have thrombophlebitis?

How to treat thrombophlebitis?

Clinical signs/diagnosis

Thrombophlebitis is the formation of blood clots in superficial veins. Larger superficial veins are not always visible externally; they run in the subcutaneous tissue, but do not belong to the deep venous system. Superficial thrombophlebitis is quite common, and sometimes it can be complicated by deep vein thrombosis or even pulmonary embolism. Thrombophlebitis most often occurs against the background of varicose veins. 65% of patients with thrombophlebitis have varicose veins. It occurs in women and men with approximately the same frequency. Factors that increase the risk of thrombophlebitis include: age over 60 years, obesity, smoking, various thrombosis in the past.

The main clinical manifestations of thrombophlebitis are painful lumps on the legs, often in the area of ​​varicose veins, as well as redness of the skin, which becomes hot to the touch. In addition, swelling may appear or worsen. Some other diseases present in a similar way, for example, soft tissue infections, erysipelas, lymphedema. In order to confirm the diagnosis of thrombophlebitis, it is necessary to perform an ultrasound duplex scanning of the veins.

Treatment of acute thrombophlebitis depends on the cause that caused it and the localization of the process. Thrombophlebitis on the hands most often appears after intravenous injections or drips. On the legs, thrombophlebitis appears mainly against the background of varicose veins due to stagnation of blood in varicose nodes. Much less often, thrombophlebitis appears in other anatomical areas - on the face, neck, chest, anterior abdominal wall. In such cases, it is necessary to be examined for cancer and hereditary disorders of the blood coagulation system.

If there are external signs of thrombophlebitis, it is necessary to perform an ultrasound examination. Duplex ultrasound scanning allows you to visualize the vein, it can be seen on the screen, and also determine whether there are blood clots inside. Moreover, the study allows you to evaluate the presence or absence of blood flow in the vein, the direction of blood flow and its speed. Ultrasound scanning is safe and can be repeated for dynamic monitoring of the condition of the veins. It is imperative to examine the deep veins, since acute thrombophlebitis in 40% of cases is accompanied by deep vein thrombosis.

Causes - etiology

The cause of thrombophlebitis cannot always be detected. In addition to varicose veins, the most common causes of thrombophlebitis are injuries and intravenous injections. About 40% with thrombophlebitis have hereditary or acquired blood clotting disorders.

Treatment methods and its duration largely depend on the localization (that is, location) of thrombophlebitis. Treatment of post-injection thrombophlebitis is mainly local - anti-inflammatory ointments and gels, compresses. In addition, tableted non-steroidal anti-inflammatory drugs, such as Ibuprofen, are prescribed to reduce pain and enhance the anti-inflammatory effect of local treatment. If the cause of thrombophlebitis was an intravenous catheter, it, of course, should be removed. Antibiotics are prescribed only if a secondary infection occurs and purulent discharge appears after removal of the intravenous catheter. In very rare cases, surgical treatment may be required if an abscess forms.

In the case of a recurrent course of thrombophlebitis, when new areas of thrombosis appear in different places, in addition to local treatment, additional diagnostics are necessary to exclude oncological diseases and systemic disorders of the blood coagulation system. This should also be done for thrombophlebitis of atypical localization (in the chest area, on the torso, etc.).

There are two fundamentally different approaches to the treatment of acute thrombophlebitis of the lower extremities: conservative and surgical. Conservative treatment consists of prescribing anticoagulants, drugs that reduce the activity of the blood coagulation system. Most often, treatment begins with low molecular weight heparins, such as Clexane or Fraxiparine. Non-steroidal anti-inflammatory drugs are also prescribed, and it is mandatory to wear compression stockings or elastic bandages. Surgical treatment is indicated in case of danger of blood clots breaking off and entering the deep veins. Indications for surgical intervention are based on ultrasound data. Special mention should be made acute ascending thrombophlebitis. in which thrombosis spreads up the great saphenous vein towards the groin, where it flows into the deep femoral vein. The operation for acute ascending thrombophlebitis involves ligating the great saphenous vein in the groin area in order to stop the process of the thrombus moving into the deep veins. This operation is called crossectomy or Troyanov-Trendelenburn operation.

With the advent of new methods of treating varicose veins, the tactics of treating acute thrombophlebitis have also changed somewhat. Thus, the radiofrequency obliteration (RFO) method can be successfully used as an alternative to surgery for acute ascending varicothrombophlebitis.

Clinical case of treatment of thrombophlebitis using RFO method

A 42-year-old patient with acute ascending thrombophlebitis on the thigh and lower leg.

What is thrombophlebitis?

Thrombophlebitis is the formation of blood clots in superficial veins. Thrombophlebitis is most often a complication of varicose veins, since favorable conditions are created in the dilated veins of the lower extremities for the formation of blood clots. The other most common cause of thrombophlebitis is intravenous injections and catheters.

Treatment of thrombophlebitis is mainly conservative. Anti-inflammatory drugs are prescribed, locally - heparin-based ointments or gels. Elastic bandaging or wearing compression stockings is also necessary. If there is a risk of blood clots entering the deep veins, for example when thrombophlebitis in the leg extends to the level of the groin, surgical treatment is necessary.

Thrombophlebitis of the lower extremities treatment and symptoms | How to cure thrombophlebitis

In medicine, thrombophlebitis of the extremities is an inflammation of the walls of the veins with the subsequent development of thrombosis. Inflammation of the venous wall (phlebitis) may precede the development of thrombosis (in these cases we speak of thrombophlebitis) or occur after it (phlebothrombosis). Most authors consider the terms “thrombophlebitis” and “phlebothrombosis” to be synonymous. The topic of our conversation is thrombophlebitis of the lower extremities, treatment and symptoms of the disease. How to cure thrombophlebitis and how to determine it, read further in the article.

Thrombophlebitis of the lower extremities - symptoms of the disease

Most often, thrombophlebitis develops in the vessels of the lower extremities, rectum, less often in the veins of the pelvis, etc. There are acute and subacute periods of thrombophlebitis. The average duration of each is up to 3 weeks. Currently, most authors do not use the term “chronic thrombophlebitis”, but consider a complication of thrombophlebitis - postthrombophlebitis syndrome.

The clinical picture of thrombophlebitis of the lower extremities includes manifestations of inflammatory and pain syndromes with pain, swelling and infiltration along the thrombosed veins, and increased body temperature. Symptoms of thrombophlebitis of the lower extremities also include occlusive syndrome due to a sharp disruption of venous outflow, with swelling and cyanosis of the foot and leg. Analysis of the state of the hemostatic system in thrombophlebitis of the extremities indicates the presence of hypercoagulation syndrome. The syndrome of hemodynamic disturbances is associated with changes in blood flow in the venous and arterial networks.

Symptoms of acute thrombophlebitis of the lower extremities

The main symptoms of thrombophlebitis.

Thrombophlebitis is an inflammatory process that affects the inner wall of a vein and is accompanied by the formation of blood clots (thrombi). The disease is characterized by a high risk of developing potentially life-threatening complications for the patient (thrombosis of the pulmonary artery or its branches, sepsis, portal vein thrombosis) and therefore in most cases requires timely surgical treatment. The most dangerous is deep vein thrombophlebitis. According to medical statistics, in developed countries, thrombophlebitis occurs with a frequency of 1-2 cases per 1,000 adults.

Thrombophlebitis is an inflammation of the venous walls with the formation of blood clots in the lumen of the vein

Forms of the disease

Depending on the depth of location of the vessels affected by the inflammatory process, thrombophlebitis of the superficial (subcutaneous) and deep veins is distinguished.

According to the activity of inflammation and the duration of the disease, thrombophlebitis can be acute, subacute and chronic. Quite often, the outcome of acute thrombophlebitis is the chronicization of the inflammatory process and its further relapsing course.

Depending on the nature of the pathological changes, thrombophlebitis can be non-purulent or purulent.

Causes of thrombophlebitis

Thrombophlebitis can affect absolutely any vein, but its favorite localization is the vessels of the lower extremities. As a rule, the disease develops against the background of long-term varicose veins. In this case, the inflammatory process initially affects the superficial veins, and then, in the absence of the necessary treatment, the deep ones.

The pathological mechanism for the development of thrombophlebitis is complex; several factors are involved in it:

• increased blood clotting;
• blood composition disorders;
• slowing down the speed of blood flow;
• damage to the walls or valve apparatus of the veins caused by any reason (trophic or endocrine disorders, diseases, injuries);
• addition of infection.

Quite often, iatrogenic factors (venesection, venipuncture) become the cause of superficial vein thrombophlebitis.

Predisposing factors to the development of thrombophlebitis are the following conditions and diseases:

• phlebeurysm;
• injuries;
• local and systemic purulent-inflammatory processes;
• postpartum period;
• postthrombophlebitic syndrome;
• some blood diseases;
• condition after abortions and surgical interventions;
• chronic diseases of the cardiovascular system;
• infectious diseases;
• long-term venous catheterization or frequent venipuncture.

The clinical picture of thrombophlebitis is largely determined by which veins are involved in the inflammatory process.

Thrombophlebitis can affect absolutely any vein, but its favorite localization is the vessels of the lower extremities.

Acute superficial thrombophlebitis most often affects varicose veins of the lower third of the thighs and upper third of the legs. In more than 95% of cases, inflammation is localized in the basin of the great saphenous vein. The main signs of thrombophlebitis in this case are:

• hyperemia (redness) of the skin in the form of stripes along the affected veins;
• increase in body temperature to subfebrile values ​​(37.5-38 ° C);
• a nagging sharp pain running along the affected vein, which significantly intensifies with physical activity.

Upon palpation, the inflamed vein is identified as a dense cord, and a local increase in temperature along the vein is also noted.

Acute thrombophlebitis of the superficial veins under favorable conditions, i.e., timely treatment ends with recovery within a period of 1 to 3 months. In most patients, the lumen of the affected vein is completely restored. In a small proportion of patients, the disease ends with obliteration (closure, fusion) of the damaged blood vessel.

If the course is unfavorable, the outcome of acute thrombophlebitis of the superficial veins can be:

• ascending thrombophlebitis (proximal spread of infection);
• thrombophlebitis of deep veins.

The likelihood of developing deep vein thrombophlebitis increases in patients suffering from varicose veins of the lower extremities and accompanied by severe insufficiency of the valvular apparatus of the vessels connecting the superficial and deep veins (perforating veins).

In approximately 50% of patients, deep vein thromboembolism is asymptomatic and is diagnosed only when complications occur and, above all, pulmonary embolism (PE), which is a life-threatening condition. In other patients, signs of the disease may include:

• bursting pain in the affected limb;
• persistent swelling of the affected limb;
• increased body temperature above 39 °C (with acute thrombophlebitis);
• Pratt's symptom (the skin becomes glossy and the pattern of the saphenous veins is clearly visible on it);
• the affected limb feels colder to the touch than the healthy one.

Symptoms of thrombophlebitis of the pelvic veins are mild signs of irritation of the peritoneum, and the development of dynamic intestinal obstruction is possible.

Diagnostics

The clinical picture of thrombophlebitis is determined by many factors:

• location of the thrombus;
• prevalence of the inflammatory process;
• the severity of pathological changes in soft tissues;
• duration of the disease.

The border of inflammation is considered not to be a dense cord, but to points of pain in a palpable vein.

According to medical statistics, in developed countries, thrombophlebitis occurs with a frequency of 1-2 cases per 1,000 adults.

To establish the extent, localization and nature of the thrombus, the degree of patency of the thrombosed vein and the condition of its wall, a number of instrumental studies are carried out:

• Doppler ultrasound of the affected veins;
• ultrasound angiography;

A laboratory blood test (general and biochemical analysis) is also carried out.

Treatment of thrombophlebitis

Conservative treatment of thrombophlebitis is indicated only for a limited pathological process that has developed in the superficial veins. In this case, patients are prescribed bed rest. The affected limb is bandaged with an elastic bandage, which allows the blood clot to be fixed in the superficial vein, and it is given an elevated position. A warming semi-alcohol or oil compress or a compress with Vishnevsky ointment are used locally.

Physiotherapeutic treatment methods (UHF, iontophoresis with thrombolytin) have a good effect.

In order to stop the activity of the inflammatory process, patients are prescribed non-steroidal anti-inflammatory drugs. If inflammation is severe, antibiotic therapy may be necessary. Acetylsalicylic acid is prescribed as a weak anticoagulant.

Ascending thrombophlebitis of the superficial veins always carries the threat of involvement of the deep veins in the pathological process. Therefore, the patient must be hospitalized in the vascular surgery department and prescribed bed rest with the limb elevated. In the first 48 hours from the moment of thrombus formation, the administration of fibrinolytic drugs is indicated in order to dissolve it. The treatment regimen also includes non-steroidal anti-inflammatory drugs, phlebotonic drugs, and anticoagulants. Gels or ointments with heparin are used locally.

If the patient has contraindications to the prescription of anticoagulants (open form of tuberculosis, kidney and liver diseases, hemorrhagic diathesis, fresh wounds, ulcers and other conditions characterized by increased bleeding), treatment with leeches (hirudotherapy) may be an alternative.

To reduce the intensity of pain and improve collateral circulation, an infiltrative novocaine blockade according to Vishnevsky is performed.

If the development of purulent thrombophlebitis is suspected and severe hyperthermia is present, antibacterial therapy is immediately started, which is carried out with broad-spectrum antibiotics.

Patients with thrombophlebitis are not recommended to remain in bed for a long time. As soon as signs of inflammation begin to subside, physical activity should gradually increase. Muscle contraction helps improve blood flow in the deep veins, thereby reducing the likelihood of blood clots and eliminating the inflammatory process more quickly. However, before activating the patient, the affected limb should be wrapped with an elastic bandage. This measure significantly reduces the risk of developing severe thromboembolic complications.

Deep vein thrombophlebitis is often accompanied by the formation of a floating thrombus. In its shape, such a blood clot resembles a tadpole and can reach a length of 20 cm, and sometimes more. The tail of a floating thrombus, under the influence of blood flow, makes constant movements and can break off at any moment, causing the development of pulmonary embolism and almost instantaneous death of the patient. Therefore, in the presence of such a blood clot, phlebologists insist on surgical treatment. The essence of the operation is to install a vena cava filter into the inferior vena cava at a level below the renal veins (a special filter that is a trap for a blood clot, which will not allow it to lead to blockage of the vessel, i.e. thromboembolism).

Thrombophlebitis is characterized by a high risk of developing potentially life-threatening complications for the patient (thrombosis of the pulmonary artery or its branches, sepsis, portal vein thrombosis), and therefore in most cases requires timely surgical treatment.

Currently, phlebology uses various methods of surgical interventions for thrombophlebitis of the superficial veins. Such operations for thrombophlebitis, especially those performed in the early stages of the disease, prevent the spread of the inflammatory process from the superficial veins to the deep ones through the system of communicating veins, prevent the disease from transitioning into a chronic recurrent form and shorten the rehabilitation period.

In case of acute ascending thrombophlebitis of the superficial veins of the leg, emergency surgical intervention is indicated, since there is a high risk of developing deep vein thrombophlebitis.

If the thrombus is localized at the mouth of the great saphenous vein, it is removed (operation for thrombophlebitis according to Troyanov-Trendelenburg).

After the acute inflammatory process subsides, patients with thrombophlebitis are recommended to undergo sanatorium-resort treatment (radon, hydrogen sulfide baths, physiotherapy, exercise therapy).

In case of exacerbation of chronic recurrent thrombophlebitis, therapy is carried out similar to that of the acute form of the disease. After the disease enters the remission stage, patients are also indicated for sanatorium-resort treatment.

Possible consequences and complications

Thrombophlebitis, if left untreated, can lead to very serious complications. The most common of them are:

• streptococcal lymphangitis;
• pulmonary embolism;
• white painful phlegmasia (develops as a result of a reflex spasm of the artery running next to the thrombosed vein);
• blue painful phlegmasia (develops against the background of a complete cessation of blood flow in the system of the femoral and iliac veins);
• purulent melting of a blood clot.

Forecast

About 20% of untreated proximal deep vein thrombosis, that is, when the thrombus is located above the leg, ends in the development of pulmonary embolism, which, in turn, can cause death. Aggressive anticoagulant therapy reduces mortality from complications of thrombophlebitis by 6–10 times.

Thromboembolism of the deep veins of the leg is almost never complicated by serious thromboembolic complications and therefore does not require anticoagulant therapy. However, thrombi from the deep venous network of the leg can penetrate into the proximal veins. Therefore, if there is a risk of such penetration, patients undergo duplex ultrasound or impedance plethysmography every 3 days for 10 days. If penetration is detected, anticoagulant therapy is started immediately.

Prevention

Prevention of the development of thrombophlebitis includes the following measures:

• timely diagnosis and adequate treatment of venous diseases;
• early activation of patients after operations and injuries;
• mandatory wearing of elastic compression means for varicose veins of the lower extremities;
• inclusion in the daily diet of foods rich in ascorbic acid and rutin (vegetables, fruits, berries).

In case of chronic thrombophlebitis, to prevent exacerbations, patients are prescribed physiotherapeutic treatment (magnetic therapy, laser therapy, electrotherapy) and medications with phleboprotective effects every three months.

Video from YouTube on the topic of the article:

Thrombophlebitis- inflammation of the venous walls with the formation of a blood clot in the lumen of the vein. Most often, with thrombophlebitis we are talking about the vessels of the lower extremities.

Etiology and pathogenesis of thrombophlebitis

Predisposing factors for thrombophlebitis serve to slow down the flow of blood, change its composition, due to which the blood loses its normal rheological properties. Thrombophlebitis can develop against the background of a blood coagulation disorder. Often the root cause of thrombophlebitis is injury to the vascular wall, endocrine disorders, infectious or allergic reactions. A number of diseases can be complicated by thrombophlebitis: varicose veins, purulent infectious diseases, hemorrhoids, tumors, blood and heart diseases.

Medical procedures (long-term catheterization) and surgical interventions on blood vessels also increase the risk of thrombophlebitis.

Clinical picture of thrombophlebitis

In clinical practice, it is customary to distinguish thrombophlebitis of superficial and deep veins.

In acute thrombophlebitis of the superficial veins of the lower extremities all symptoms occur, as a rule, on already varicose vessels. Most often, the great saphenous vein is affected.

Along the course of the vein, a nagging pain occurs; upon palpation, a painful cord is identified. In this case, it is possible to increase the temperature to subfebrile values, less often - to febrile. Skin hyperemia is observed above the vein. With thrombophlebitis of large arteries, thrombus rupture and pulmonary embolism are possible.

Clinic for thrombophlebitis of deep veins of the leg depends on the size and location of the blood clot, as well as the number of affected veins. Thrombophlebitis usually manifests itself with sudden sharp pain in the calf muscles, a feeling of swelling in the lower leg. These symptoms may increase when walking down stairs. Thrombophlebitis of the deep veins of the lower extremities is often accompanied by an increase in body temperature.

Upon examination, edema of the distal parts of the lower extremities is revealed, the skin over the affected area becomes cyanotic. Dorsiflexion of the foot causes severe pain in the calf muscles.

To the early symptoms of thrombophlebitis of the deep extremities include Moses sign, which consists in the appearance of pain when squeezing the lower leg in the anteroposterior direction and the absence of pain when squeezing from the sides. To identify Opitz-Ramines sign A sphygmomanometer cuff is placed on the affected limb above the knee and the pressure is inflated to 40-45 mm Hg. Art. In this case, a sharp pain appears along the veins; after the pressure is reduced, the pain goes away. The mechanism of occurrence is similar to the Opitz-Ramines symptom. Lowenberg's sign- the appearance of sharp pain in the calf muscles at a pressure of 60-150 mm Hg. st in a cuff placed on the middle third of the lower leg.

During development thrombophlebitis of the femoral vein before the deep vein flows into it the pain syndrome is not so pronounced, since the good development of collateral circulation in this place compensates for the resulting difficulty in venous outflow. Examination of the area of ​​thrombophlebitis reveals the presence of slight edema and dilatation of the saphenous veins.

Damage to the common femoral vein characterized by more pronounced symptoms - significant pain, severe swelling and cyanosis of the skin. Expansion of the saphenous veins is observed in the upper third of the thigh, in the groin and pubic areas. Body temperature rises to high levels, accompanied by chills.

The most severe thrombophlebitis of the iliofemoral section of the main vein. In the initial stage of the disease or when the vessel is not completely blocked by a blood clot, minor pain gradually appears in the lower back and sacrum, and in the lower abdomen on the affected side. Patients note the appearance of weakness and malaise. A life-threatening condition, pulmonary embolism, can be caused by floating blood clots.

Complete iliac vein occlusion is characterized by sharp pain in the groin area, the development of widespread edema, covering the buttock and groin areas, spreading to the genitals and the anterior abdominal wall. The swelling is soft at first, but after some time it becomes dense. The skin over the affected area becomes milky white or purple in color. Upon examination, an increase in the venous pattern is revealed. The patient's general condition worsens, body temperature rises (38-39°C), chills, lethargy, and adynamia appear.

Treatment of thrombophlebitis

The most effective treatment for thrombophlebitis is surgery..

However, in some cases, for example, when previously unchanged veins are affected or in cases where surgery is impossible for some reason, conservative treatment is indicated.

Progressive ascending thrombophlebitis of the great and small saphenous veins is an indication for emergency surgery to avoid the development of serious complications, one of which is thromboembolism.

Conservative treatment includes elevating the affected limb and applying cold. It is recommended to lubricate the site of thrombophlebitis with ointment with heparin or troxevasin. To relieve inflammation and eliminate congestion, ointments with indromethacin, venoruton, and anavenol are used. A severe inflammatory process requires systemic antibiotics. Tight elastic bandaging of the legs is of great importance for thrombophlebitis. UHF therapy has a good effect.

Patients with thrombophlebitis of the deep veins of the lower extremities are subject to hospitalization. Bed rest is prescribed with the lower limbs elevated by 20°, which should be bandaged. Therapy is carried out aimed at lysing the thrombus (streptokinase, urokinase) and preventing the progression of thrombus formation (heparin, rheopolyglucin, pentoxifylline).

Motor activity is allowed from 5-10 days in the form of slow flexion and extension of the legs, first in bed, then slow walking.

Comments

Olga August 17, 2011 I hope that Internet users who read this article will tell and warn their elderly loved ones against scammers, because the amount required for installing a “preferential filter” is equal to the amount of the pension, and the scammers come just in numbers when the pension should already be received and is kept in grandma's box; in addition, if there is not enough money, arrogant sellers offer to borrow the missing amount from neighbors or relatives. And grandmothers are responsible and respectable people, they themselves will go hungry, but they will pay off the debt for the unnecessary filter... Vasya April 18, 2012 decide on your location on the map Alexei August 17, 2011 It would be better if they sold books in offices as before :( Alexei August 24, 2011 if you have any problems using the program, please leave your comments here or email the author Milovanov Evgeniy Ivanovich August 26, 2011 Thank you, the program is good. If it is possible to make changes - the continuation of the certificate of incapacity for work by another user, we cannot remove the disease code, date of issue, gender. If it would be possible to simply make blank fields here, that would be great. Milovanov_ei vsw.ru EVK August 27, 2011 For doctors and health care facilities: the website http://medical-soft.narod.ru contains the SickList program for filling out sick leave certificates by order of the Ministry of Health of the Russian Federation No. 347-n dated April 26, 2011.
Currently, the program is successfully used in the following health care facilities:
- GP No. 135, Moscow
- GB N13, Nizhny Novgorod
- City Clinical Hospital No. 4, Perm
- LLC “First Emergency Room”, Perm
- JSC MC "Talisman", Perm
- "Philosophy of beauty and health" (Moscow, Perm branch)
- MUZ "ChRB No. 2", Chekhov, Moscow region.
- GUZ KOKB, Kaliningrad
- Cher. Central district hospital, Cherepovets
- MUZ "Sysolskaya Central District Hospital", Komi Republic
- Rehabilitation Center LLC, Obninsk, Kaluga region,
- City Clinical Hospital No. 29, Kemerovo Region, Novokuznetsk
- Polyclinic KOAO "Azot", Kemerovo
- MUZ Central Regional Hospital of the Saratov region
- Polyclinic No. 2 of the Kolomenskaya Central District Hospital
There is information about the implementation yet
in approximately 30 organizations, incl.
in Moscow and St. Petersburg. Lena September 1, 2011 Cool! I had just read the article when...the doorbell rang and my grandfather was offered a filter! Anya September 7, 2011 I, too, at one time encountered acne, no matter what I did, no matter where I turned... I thought that nothing would help me, it seemed to be getting better, but after a while my whole face was scary again, I no longer trusted anyone. Somehow I came across the magazine “Own Line” and there was an article about acne and how you can get rid of them. I don’t know what pushed me, but I again turned to the doctor who commented on the answers in that magazine. A couple of cleansings, several peelings and three laser treatments, everything is fine with my home cosmetics, and you should have seen me. Now I can’t believe that I had such a problem. It seems that everything is real, the main thing is to get into the right hands. Kirill September 8, 2011 Wonderful doctor! A professional in his field! There are few such people! Everything is done very efficiently and painlessly! This is the best doctor I have ever met! Andrey September 28, 2011 Very good specialist, I recommend him. A beauty too... Artyom October 1, 2011 Well, I don’t know...My aunt also installed a filter from them. She says she's happy. I tried the water. It tastes much better than from the tap. And in the store I saw five-stage filters for 9 thousand. So, it seems they are not scammers. Everything works, the water flows decently and thank you for that.. Sergey Ivanovich October 8, 2011 There is no point in slandering them, the system is excellent, and everything is in order with their documents, my wife checked, she is a lawyer by training, and I want to say thank you to these guys, so that you go shopping and look for this filter, and here They brought it to you, installed it, and they also fix any problems, I have had this system for more than 7 months. the filters were changed, everything was fine, you should have seen the condition of the filters, they were all brown in mucus, terrible in one word, and those who don’t install them simply don’t go to think about themselves and their children, but now I can safely pour water for my child from the tap, without fear! Svetlana October 19, 2011 The most disgusting hospital I have ever known!!! Such a boorish and consumerist attitude towards women - you’re simply amazed how this can still happen in our time! I arrived in an ambulance with bleeding and went to bed to continue my pregnancy. They convinced me that it was impossible to continue the pregnancy, that there was already a miscarriage, now we will clean you up and everything will be fine! Imagine! She asked for an ultrasound, and the ultrasound showed that the child was alive, the heart was beating, and the child could be saved. I couldn’t get it cleaned, they had to put me in storage. She was treated with Vikasol and papaverine. ALL!!! No vitamins, no IVs, NOTHING! Well, okay, thank God, I escaped from there after 3 days and was treated at home. The treatment was prescribed by my gynecologist, IVs were also given at home... It is still unknown how it would have ended if I had stayed there for another week... But now everything is fine, in August I gave birth to a girl, healthy, strong... Now he is calling me my sister. She's at the cons. Yesterday they said that she is pregnant, 3 weeks due. Today I started bleeding with clots, etc. I did an ultrasound and was told to run to the hospital for cleaning. The duty officer AS ALWAYS Avtozavodskaya... But they didn’t accept her!!! Bleeding! The hospital is on duty!!! Just bitches! And they also talk so rudely... I will find justice for you, I will immediately call where necessary. And I leave this comment for others - so that they bypass this lair... Elenna October 25, 2011 spent my childhood there. liked.
Although I really didn’t like injections, nor did I like massages. Elena October 25, 2011 Yes, a lot of people have a grudge against this hospital! Good luck Svetlana in your affairs. I have the same opinion about this hospital. Elena October 25, 2011 who works and how. or rather promotes the product. I had aquaphor (a jug), so the water from it is also much better than tap water!
The point is to impose your product, as I understand it. Now they run from Zepter like fire. just because of excessive intrusiveness. Mila October 25, 2011 I really like it there, qualified specialists, and they try not to smuggle anything in, but to pick it up! I will note one of the minuses. queues. Quite a popular center. And thank you very much for lenses and solutions without a crazy markup! Misha October 25, 2011 In my work I came across distributors of various electronic cigarette manufacturers. And there are fig ones - like pons, and there are good ones - like rich. Unfortunately, in Izhevsk they sell the cheapest, that is, the most crappy ones. But! There is no smell from electronic cigarettes! And their advantage is that there are no resins, which are carcinogens! Quit smoking. It's hard with their help. and not disturb others and significantly reduce the harm from cigarettes - it will work out! Danya October 25, 2011 here you go, crooks! plundered!!! Elena January 28, 2012 In December we were there, they held a meeting, I was offended by the quality of our water, I’m from Kazan, but then they didn’t supply it, my son said it wasn’t necessary! But recently I went to a store with a geyser, they also have 5 stages, the same price here 9700, now you don’t even know, you should have installed it because that’s how they cost, they sell it right at home and without store markups! You need to make sure that all the documents are in order before you buy. no name January 28, 2012 here you decide for yourself whether you want it or not! It’s not like they’re forcing him to install it. There’s still an agreement, first they’ll install it and then they’re unhappy with something, you have to think first when you’re giving the money. nonsense Catherine January 29, 2012 Now also in Cheboksary, Chuvash Republic....People, be careful! Nika January 26, 2012 I work in a rural area. Ours are paid compensation of approximately 100 - 300 rubles. What is this for? But you won’t expect anything from our head of the district health department. And in general - how long can you tolerate such boors and ignoramuses (bosses) because of which the personnel in literally "flow"?! Aksinya November 28, 2011 I was there once: after finding out whether it was possible to do an ECG, they told me to come the next day at 16:00, in the end I came, but they told me no, there is no one to do it, or wait another hour until the doctor comes. In the end, I waited an hour, they did it, asked without a description, as it turned out the price with and without a description was the same, although the day before they said that without a description it was cheaper.
Conclusion: I didn’t like the girls at the reception, they had sour facial expressions. It feels like they are doing me a favor. Vadyai November 28, 2011 I recently had an appointment with you, the impressions were very good, the staff was friendly, the doctor explained everything correctly at the appointment, they immediately did an ultrasound and passed tests
I had an appointment at Pushkinskaya, tests and ultrasound at Sovetskaya... thank you all so much!!!
Special greetings to Alexey Mikhalych!!!