Investigations
1st investigations to order
Doppler ultrasonography
Test
Although the diagnosis of superficial vein thrombosis (SVT) is primarily clinical, duplex ultrasound is recommended for all patients to exclude concurrent ipsilateral deep vein thrombosis (DVT), to confirm the clinical diagnosis of SVT, and to show thrombus extension and proximal thrombus location in reference to the saphenofemoral and saphenopopliteal junctions.[1] Ultrasound of the contralateral limb at the time of diagnosis is reserved for patients with symptoms or those at high-risk for thrombosis, such as in patients with hypercoagulable state.
Doppler ultrasonography has been shown to be highly sensitive (>95%) and specific (>95%) to diagnose symptomatic and asymptomatic proximal vein DVT.[51][52] The sensitivity and specificity for SVT is not known.
Ultrasonography may also be used for follow-up to confirm absence of thrombus propagation, especially in patients with a poor response to therapy.
Result
lack of compressibility or intraluminal thrombus in the superficial veins
Investigations to consider
biopsy
Test
Small vessels in the superficial dermis are characteristically spared.[57]
A biopsy should be ordered in superficial vein thrombosis cases that are recurrent and/or migratory, and when inflammatory diseases such as polyarteritis nodosa are being considered. This is best accomplished by an elliptical incision transverse to the long axis of the vessel rather than a punch biopsy.
In early lesions, there is a dense inflammatory cell infiltrate mainly composed of neutrophils within the vessel wall. The vein wall appears markedly thickened as a result of exudation of inflammatory cells and oedema. The endothelial cells are swollen. There are thrombi occluding the lumina of the affected veins that eventually undergo recanalisation.
Result
thrombosis involving large- and medium-sized veins of the upper subcutis and lower dermis
pulmonary CT angiography
Test
In patients with suspected superficial vein thrombosis with concomitant respiratory symptoms or signs of PE (chest pain, dyspnoea, syncope), pulmonary CT angiography or a ventilation perfusion scan to look for concomitant PE should be performed.
Result
exclude pulmonary embolism (PE)
ventilation perfusion (VQ) scan
Test
In patients with suspected superficial vein thrombosis with concomitant respiratory symptoms or signs of PE (chest pain, dyspnoea, syncope), pulmonary CT angiography or a ventilation perfusion scan to look for concomitant PE should be performed.
Result
exclude pulmonary embolism (PE)
conventional pulmonary angiography
Test
Indicated if pulmonary CT angiography or a VQ scan is inconclusive and PE is still suspected.
Result
exclude pulmonary embolism (PE)
assessment for malignancy
Test
This is indicated in patients with superficial vein thrombosis (SVT) not associated with varicose veins; extensive saphenous vein thrombosis on Doppler ultrasonography, with or without concomitant deep vein thrombosis or pulmonary embolism; or recurrent or idiopathic SVT.
Result
malignancy
thrombophilia screening
Test
Screening for thrombophilic disorders may be useful in patients with superficial vein thrombosis (SVT) not associated with varicose veins; extensive saphenous vein thrombosis on Doppler ultrasonography, with or without concomitant deep vein thrombosis or pulmonary embolism; recurrent SVT; idiopathic SVT. It can also be considered for patients with an above-knee SVT, but this may not be necessary for patients with large varicose veins/superficial venous incompetence and a first-time above-knee SVT.
However, the utility and cost-effectiveness of screening for thrombophilic states in patients with SVT has not been well studied.
Result
presence of factor V Leiden and prothrombin G20210A genetic variants; deficiencies of protein S, C, and antithrombin III; positive lupus anticoagulant and anticardiolipin antibodies; hyperhomocysteinaemia
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