Thrombophlebitis 

Thrombophlebitis is the condition with inflammation of the veins or arteries caused due to the blood clots. Majority of the cases are the inflammation in the legs but in some rare cases inflammation can occur in arms and neck. 

There are various types of thrombophlebitis, like superficial thrombophlebitis, that occurs just under the skin which is visible. While touching the tender, warmness and pain can be felt along with the visible redness and swelling.

Risk factors for thrombophlebitis

• Less physical activity; maybe due to injury, surgery or long time sitting
• Due to pregnancy or recent childbirth
• Oral contraceptive use, HRT or estrogen therapy
• Stroke or other diseases which causes limitation of movement
• Genetic disorder related to blood clotting
• Prior use of central venous catheter for any injection or dialysis procedure
• Cancer¹

Varicose veins

Varicose veins are subcutaneously dilated veins specifically in lower extremities involving saphenous vein, saphenous tributaries or non saphenous superficial leg veins. 

Varicose veins can be subcutaneous dilated, tortuous veins, saphenous tributaries or non-saphenous superficial leg veins with age and genetic causes are the major factors. Varicose veins are chronic diseases. 

Risk factors for varicose veins

• Age
• Gender- females are more susceptible to this condition
• Pregnancy
• Height 
• Obesity
• Race
• Diet
• Occupation ( prolonged standing and walking)
•  Constipation
• Medical history of thrombosis
• Family history of thrombosis
• Oral contraceptives
• Also some other associated factors are Smoking, Circulating iron

Diagnosis

• Based on symptoms, a colour duplex venous ultrasound exam can be obtained
• Duplex sonography markers are used for indexing of varicose vein grading study
• Contrast venography
• Pulsed-wave Doppler images help with demonstration of retrograde blood flow

Treatment

Injection Sclerotherapy: by utilizing chemical irritants destroy the unwanted superficial veins. This is primarily used to treat small nonaxial varicose veins with diameter less than 6mm diameter. Polidocanol is used to manage the varicose veins and spider veins. Current application of cyanoacrylate glue to treat chronic varicose veins are preferred.

Conservative Treatments: the most used symptom relief, is long-term use of compression stockings, leg elevation and oral pain medications. Also heat and hot weather can reduce the pain and symptoms.

Surgical Treatment: this method involves ligation and removal of the veins. This method is chosen based on the location, size and the extent of the venous involvement with or without venous reflux. There are various methods like saphenous vein inversion and removal, high saphenous ligation, ambulatory phlebectomy, transilluminated powered phlebectomy and endovascular management.

Prognosis: for varicose veins there is no cure, recurrence is common even after the surgical removal. 

Other complications

• Pain
• Poor cosmesis
• Venous ulcers
• Deep vein thrombosis
• Pulmonary embolism 
• Superficial thrombophlebitis 
• Superficial vein thrombosis²

Physiology

Muscle pumps located in the foot and the calf are the reason for the venous return against gravity. The pressure to the sole of the foot and muscle contractions of the calf will compress the sinusoidal intramuscular veins which directs the blood to the deep systems to up the leg. The blood from superficial tissue will be collected in superficial veins during relaxation of the muscle the blood enters the deep system and enters the sinuses. Reverse flow is prevented during muscle relaxation due to closure of valves. While standing or sitting motionless for long the venous valves will be in the neutral position, the blood pressure increases (venous hypertension) in the foot or leg. The failure of venous valve closure compresses the deep veins and sinuses due to increase in the venous pressure, causing the dilated elongated and tortuous vein along with accumulation of interstitial fluid or oedema in the feet.³

Mechanism of increased susceptibility to thrombophlebitis

Venous stasis: the occurrence of thrombosis is very high in case of deep vein thrombosis (DVT) with immobility, external pressure (like tumour) on veins, catheter related arm vein thrombosis, recurrent DVT which caused prior scars and clots.

Hypoxemia: during hypoxia for the formation of fibrin tissue factor (TF) is necessary. Hypoxia elevated plasminogen activator inhibitor-1, which will suppress fibrinolysis along with other factors like elevated clotting proteins and activation of platelets increase the risk of thrombosis. 

Reduced clearance in valve pockets: the greater saphenous vein has a valve sinus which is responsible for the anticoagulant environment. The venous stasis condition, the von Willebrand factor levels in valvular areas, contributes to a shift to hypercoagulability. Which activates platelets, leukocytes, prothrombin etc. leading to thrombosis.

A genetic component: if the person is having rare genetic variants like natural anticoagulant variants (Protein C, Protein S, antithrombin), STAB2 gene (which impairs protein transport including von Willebrand factor) are linked to venous thromboembolism.⁴

Treatment or management

To prevent pulmonary embolism, reduce morbidity and the risk of post thrombotic syndrome, anticoagulation treatment is suggested.

• Low molecular weight heparin and factor Xa inhibitors: this medication is used in the condition of cancer associated with thromboembolism. If the cancer is recently diagnosed, extensive venous thromboembolism, or if there is any adverse effect regarding the mentioned treatment, then the higher levels of anticoagulation should be considered
• Rivaroxaban, edoxaban, vitamin K antagonists are preferred in once daily oral therapy
• If the patient is suffering with liver disease, low molecular weight heparin should be advised. In the case of raised INR levels, direct oral anticoagulants are contraindicated
• If the patient is positive to renal disease with suppressed creatinine clearance below 30 ml/min and end stage renal diseases, vitamin K antagonists are prescribed. As direct oral anticoagulants and low molecular weight heparins should be avoided
• The patients with coronary artery disease are advised to take vitamin K antagonist, rivaroxaban, apixaban and edoxaban
• The patient with past history of gastric bleeding and dyspepsia should avoid certain medications like direct oral anticoagulants like dabigatran, factor Xa inhibitors like rivaroxaban, selective factor Xa inhibitors like edoxaban may lead to increased GI bleeding. In this condition vitamin K anticoagulants and apixaban are prescribed
• The patients with poor compliance were given vitamin K anticoagulants, but can be prescribed with other medications with high compliance
• There are no direct oral anticoagulants available universally thus the medication should be prescribed accordingly if there is any subjected reversal thrombolytic therapy
• Most of the anticoagulants will cross the placenta so during pregnancy low molecular weight heparin is preferred therapy⁵

Summary 

Varicose veins are dilated subcutaneously. These affect lower extremities majorly involving the saphenous vein. These are chronic conditions based on factors like age, gender (high prevalence in females), pregnancy, height, obesity, race, diet, occupation (prolonged sitting or walking), constipation, history of thrombosis, oral contraceptives, smoking, circulating iron and genetic (family history) factor, without any cure, as these are recurring conditions. The diagnosis is based on the symptom, colour duplex venous ultrasound, Duplex sonography markers for grading and Contrast venography and pulsed-wave Doppler for detecting retrograde blood flow. 

Prognosis and complications: Even after surgery there's no permanent cure, and recurrence is common. There are potential risks including pain, poor cosmesis, venous ulcers, deep vein thrombosis, pulmonary embolism and superficial thrombosis.

There are various therapies like anticoagulant therapy and medications used are LMWH, Factor Xa inhibitors, Rivaroxaban, Edoxaban, Vitamin K Antagonists are used to treat varicose veins.