N.B. This guideline relates to non-pregnant adults.
Superficial vein thrombosis, also known as superficial thrombophlebitis (STP), is a common condition, likely more common than deep vein thrombosis. It is a painful condition affecting the superficial veins, usually of the lower limbs. It should not be confused with superficial femoral vein thrombosis, as this is thrombosis in a deep vein and requires full anticoagulation therapy.
STP can occur alone or in association with deep vein thrombosis (DVT). In people with STP 6-44% are associated with or develop DVT, 20-33% with asymptomatic pulmonary embolism (PE) and 2-13% with symptomatic PE. Those associated with the great saphenous vein appear to have the strongest association with venous thromboembolism.
The aims of management include:
STP is usually a clinical diagnosis based on symptoms of localised swelling, erythema and pain with tenderness over the affected vein. Patients should be assessed for risk factors for DVT and an assessment using the Wells score should be carried out to encourage consideration of this complication. Any chest symptoms should also be taken seriously and PE considered in the differential.
Most patients presenting to hospital with symptoms suggestive of STP should have a compression Doppler USS to assess the length and position of the superficial thrombus and exclude a concurrent DVT.
Note:
Those presenting with STP in the community should be referred to their local DVT service for a Doppler USS if there is either clinical evidence of concurrent DVT or the STP has features indicative of a high risk of STP extension, recurrence or progression to DVT. The DVT pageholder can be contacted via switchboard.
These include the following:
These recommendations are based on the fact that studies of the epidemiology and natural history of STP have focused on cases referred to hospital or vascular laboratories for assessment and therefore are likely biased towards the more clinically severe forms of the condition. Furthermore, the evidence for aggressive treatment of STP, as outlined below, is limited to those presenting to secondary care.
Any STP <3cm from the saphenofemoral junction (SFJ) should be treated as a DVT as the rate of extension to DVT in these patients is very high.
Various treatments have been used for STP, including compression stockings, NSAIDs, LMWH, rivaroxaban, surgical intervention and topical agents.
Two recent studies have demonstrated both fondaparinux and rivaroxaban to be effective in the management of STP, resulting in a reduction in the incidence of DVT and PE. In one study, fondaparinux was demonstrated to be superior to placebo. Due to non-submission, fondaparinux is not recommended by SMC. A more recent study has demonstrated that rivaroxaban is non-inferior to fondaparinux with no increased risk of bleeding.
Based on the above data, it is recommended that patients with a STP of >5cm in length, who do not meet the criteria for therapeutic anticoagulation, receive rivaroxaban 10mg once daily for 6 weeks, as long as there are no contraindications to its use.
Rivaroxaban should be used in preference to fondaparinux for the following reasons:
If rivaroxaban is not suitable or contraindicated, dalteparin should be used as this is the prophylactic LMWH used in NHS Ayrshire & Arran. The use of dalteparin or rivaroxaban for this indication is off-label.
Example Details of Doppler USS request: 'Suspect STP in greater saphenous vein proximal to the knee. Please assess length and site of STP (in relation to the SFJ) and exclude DVT' |
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No STP or DVT identified | STP ≤3cm from SFJ | STP >3cm from SFJ; STP ≥5cm in length | STP >3cm from SFJ; STP <5cm in length |
Alternative diagnosis for symptoms should be sought |
Therapeutic anticoagulation for 3 months (as per DVT guideline ADTC302 on AthenA - link only active if accessing via NHS network) |
Rivaroxaban oral 10mg once daily for 6 weeks (42 days) - off-label |
NSAIDs for 8-12 days for symptomatic relief only |
Unsuitability for rivaroxaban would include (refer to BNF for interactions and contraindications):
Guideline reviewed | December 2022 |
Page updated | January 2025 |