Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

extension into the femoral vein or popliteal vein, thrombus ≤3 from the saphenofemoral or saphenopopliteal junction, or concomitant DVT or PE

1st line – management according to venous thromboembolic protocol

Back
INITIAL
|
extension into the femoral vein or popliteal vein, thrombus ≤3 from the saphenofemoral or saphenopopliteal junction, or concomitant DVT or PE
|
anticoagulation not contraindicated
1st line – 

management according to venous thromboembolic protocol

Must be treated according to venous thromboembolism practice guidelines, including therapeutic doses of anticoagulation for at least 3 months.​​[62][75]

First-line therapy includes treatment doses of a direct oral anticoagulant (DOAC); or low molecular weight heparin (LMWH), unfractionated heparin, or fondaparinux, followed by warfarin to target INR 2.5. During pregnancy, LMWH is recommended.

See Deep vein thrombosis.

A thorough assessment of bleeding risk should be undertaken before prescribing an anticoagulant. DOACs should be used with caution in patients with renal insufficiency; a dose adjustment or an alternative treatment (e.g., heparin, warfarin) may be required.[69]​ Surveillance for heparin-induced thrombocytopenia may be necessary in some cases.

1st line – ligation or inferior vena cava filter

Back
INITIAL
|
extension into the femoral vein or popliteal vein, thrombus ≤3 from the saphenofemoral or saphenopopliteal junction, or concomitant DVT or PE
|
anticoagulation contraindicated
1st line – 

ligation or inferior vena cava filter

Where anticoagulation is contraindicated, ligation with or without thrombectomy may be indicated, where local expertise is available. If the thrombus extends into the common femoral vein substantially, placement of an optional inferior vena cava (IVC) filter is appropriate, with retrieval as soon as the contraindication to anticoagulation has resolved.

During pregnancy, an IVC filter may be placed but typically in the suprarenal location due to the gravid uterus. Ligation of the saphenofemoral or saphenopopliteal junction (depending on where the superficial vein thrombosis [SVT] is located) is also an option during pregnancy, but may require general anesthesia. IVC ligation is not typically an option during pregnancy.

Even in patients in whom therapeutic anticoagulation for treatment of SVT is contraindicated, prophylactic low molecular weight heparin (LMWH) is nevertheless recommended postoperatively for at least 7-10 days to reduce postoperative venous thromboembolism (VTE). Once there is no longer a contraindication to therapeutic anticoagulation, therapeutic LMWH or unfractionated heparin should be started or resumed, to reduce VTE complications.

Primary options

enoxaparin: prophylaxis: 40 mg subcutaneously once daily

OR

dalteparin: prophylaxis: 5000 units subcutaneously once daily

ACUTE

non-pregnant: SVT ≥5 cm in length within axial superficial vein and >3 cm from the saphenofemoral or saphenopopliteal junction

1st line – prophylactic anticoagulation

Back
ACUTE
|
non-pregnant: SVT ≥5 cm in length within axial superficial vein and >3 cm from the saphenofemoral or saphenopopliteal junction
|
anticoagulation not contraindicated
1st line – 

prophylactic anticoagulation

Prophylactic anticoagulation is recommended for all patients with a superficial thrombus ≥5 cm in length within the great saphenous, small saphenous, or anterior accessory great saphenous veins and >3 cm from the saphenofemoral or saphenopopliteal junctions.[44][62][64]​​[65]​​

Guidelines recommend 45 days of anticoagulation, with prophylactic doses of fondaparinux as the preferred option.[60][62][65]​​ Recommended alternatives include prophylactic- or intermediate-dose low molecular weight heparin (LMWH), or oral rivaroxaban for patients who decline or are unable to use parenteral anticoagulation.[60][62]​ Intermediate doses are larger than prophylactic doses, and smaller than treatment doses. The 2023 European Society for Vascular Surgery (ESVS) guideline on antithrombotic therapy recommends intermediate-dose LMWH, as data suggests it is more effective than prophylactic-dose LMWH at preventing recurrent events.[65]

Other options include unfractionated heparin (UFH) alone, or warfarin overlapped with 4 days of UFH or LMWH and continued for 45 days. These options are no longer commonly used in the US but may be indicated in rare circumstances (e.g., critically ill hospitalised patients). Use of UFH is supported by weak evidence.[70][74]​ Warfarin has largely been replaced by alternative options because it requires frequent monitoring and is associated with an increased risk of bleeding.[69]

The elevated rates of venous thromboembolism among high-risk patients found in clinical trials suggest that high-risk patients with superficial vein thrombosis (SVT) may require treatment for longer than 45 days, but data to support a specific duration are lacking.[71][73]​​​ The ESVS guideline recommends considering treatment with intermediate-dose anticoagulation for 3 months in patients with high-risk features (e.g., extensive SVT involving both the calf and thigh, absence of local pain, axial SVT, multiple sites of thrombosis).[65]

A thorough assessment of bleeding risk should be undertaken before prescribing an anticoagulant. Direct oral anticoagulants should be used with caution in patients with renal insufficiency; a dose adjustment or an alternative treatment (e.g., heparin, warfarin) may be required.[69]​ Surveillance for heparin-induced thrombocytopenia may be necessary in some cases. 

A repeat Doppler ultrasound following the start of anticoagulant therapy may be required to assess for SVT extension, especially for proximal greater saphenous vein SVT treated with intermediate or prophylactic doses of LMWH, prophylactic doses of fondaparinux, or intermediate doses of UFH.

Consult specialist or local protocols for guidance on dose.

Primary options

fondaparinux

Secondary options

rivaroxaban

OR

enoxaparin

OR

dalteparin

Tertiary options

heparin

OR

enoxaparin

or

dalteparin

or

heparin

-- AND --

warfarin

Consider – supportive therapy

Back
ACUTE
|
non-pregnant: SVT ≥5 cm in length within axial superficial vein and >3 cm from the saphenofemoral or saphenopopliteal junction
|
anticoagulation not contraindicated
Consider – 

supportive therapy

Additional treatment recommended for SOME patients in selected patient group

Compression stockings are usually prescribed for 10-14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings to help in the resolution of inflammation and superficial vein thrombosis (SVT), are recommended. They are put on in the morning before getting up and removed in the evening when going to bed.

Compression therapy has not been shown to prevent SVT extension or thromboembolic complications.

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index is <0.8. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

Local heat and leg elevation may help alleviate acute symptoms.

Ice may also be used instead of heat initially to decrease inflammation.

1st line – ligation

Back
ACUTE
|
non-pregnant: SVT ≥5 cm in length within axial superficial vein and >3 cm from the saphenofemoral or saphenopopliteal junction
|
anticoagulation contraindicated
1st line – 

ligation

Where anticoagulation is contraindicated, treat surgically with ligation of the saphenofemoral or saphenopopliteal junction (depending on where the superficial vein thrombosis [SVT] is located), with anticoagulation initiated when the reason for the contraindication has resolved.

Even in patients in whom therapeutic anticoagulation for treatment of SVT is contraindicated, prophylactic low molecular weight heparin (LMWH) is nevertheless recommended postoperatively for at least 7-10 days to reduce postoperative venous thromboembolism (VTE).

Once there is no longer a contraindication to therapeutic anticoagulation, therapeutic LMWH or unfractionated heparin should be started or resumed, to reduce VTE complications.

Primary options

enoxaparin: prophylaxis: 40 mg subcutaneously once daily

OR

dalteparin: prophylaxis: 5000 units subcutaneously once daily

Consider – supportive therapy

Back
ACUTE
|
non-pregnant: SVT ≥5 cm in length within axial superficial vein and >3 cm from the saphenofemoral or saphenopopliteal junction
|
anticoagulation contraindicated
Consider – 

supportive therapy

Additional treatment recommended for SOME patients in selected patient group

Compression stockings are usually prescribed for 10-14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings to help in the resolution of inflammation and superficial vein thrombosis (SVT), are recommended. They are put on in the morning before getting up and removed in the evening when going to bed.

Compression therapy has not been shown to prevent SVT extension or thromboembolic complications.

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index is <0.8. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

Local heat and leg elevation may help alleviate acute symptoms.

Ice may also be used instead of heat initially to decrease inflammation.

non-pregnant: SVT <5 cm in length within axial superficial vein or thrombus within tributary varicose veins only

1st line – non-steroidal anti-inflammatory drugs (NSAIDs) + monitor for propagation

Back
ACUTE
|
non-pregnant: SVT <5 cm in length within axial superficial vein or thrombus within tributary varicose veins only
1st line – 

non-steroidal anti-inflammatory drugs (NSAIDs) + monitor for propagation

Oral NSAIDs, usually in combination with elastic bandages or compression stockings, can be considered as first-line therapy for superficial vein thrombosis (SVT) that only involves tributaries of varicose veins.[62]​ NSAIDs may also be considered first-line if the thrombus in the affected saphenous vein is less than 5 cm in length and in the below-knee great saphenous vein. However, as many of these patients exhibit progression when followed clinically, prophylactic-dose anticoagulation may be warranted.

NSAIDs can alleviate symptoms and may prevent SVT extension and recurrence.[68][78]​​ However, one Cochrane review found that NSAIDs do not influence the rate of venous thromboembolism or resolution of symptoms.[70]

NSAIDs should not be prescribed in patients at higher risk of thromboembolism (e.g., extensive SVT with involvement above the knee, particularly if within 3 cm of the saphenofemoral junction; thrombus ≥5 cm in length; severe SVT symptoms; involvement of the greater saphenous vein; history of venous thrombosis or SVT; active cancer).

Contraindications to NSAIDs (such as peptic ulcer disease) should be considered before they are prescribed, and they should not be given in combination with anticoagulants due to the increased risk of bleeding.[77]

Patients treated with NSAIDs should have close clinical follow-up and serial ultrasound examinations as necessary to monitor for extension.

Primary options

ibuprofen: 400 mg orally four times daily

OR

diclofenac potassium: 50 mg orally (immediate-release) two or three times daily

OR

naproxen: 500 mg orally once or twice daily

OR

piroxicam: 10 mg orally once or twice daily

OR

indometacin: 50 mg orally two or three times daily

Consider – supportive therapy

Back
ACUTE
|
non-pregnant: SVT <5 cm in length within axial superficial vein or thrombus within tributary varicose veins only
Consider – 

supportive therapy

Additional treatment recommended for SOME patients in selected patient group

Compression stockings are usually prescribed for 10-14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings to help in the resolution of inflammation and superficial vein thrombosis (SVT), are recommended. They are put on in the morning before getting up and removed in the evening when going to bed.

Compression therapy has not been shown to prevent SVT extension or thromboembolic complications.

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index is <0.8. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

Local heat and leg elevation may help alleviate acute symptoms.

Ice may also be used instead of heat initially to decrease inflammation.

1st line – prophylactic anticoagulation

Back
ACUTE
|
non-pregnant: SVT <5 cm in length within axial superficial vein or thrombus within tributary varicose veins only
1st line – 

prophylactic anticoagulation

In patients with one or more venous thromboembolism (VTE) risk factors, there may be a benefit from treatment with prophylactic anticoagulation with low molecular weight heparin (LMWH, e.g., enoxaparin, dalteparin), fondaparinux, or rivaroxaban, rather than non-steroidal anti-inflammatory drugs (NSAIDs).[62]​ While NSAIDS are an option if the thrombus in the affected saphenous vein is less than 5 cm in length and in the below-knee great saphenous vein, many of these patients exhibit progression when followed clinically, and thus prophylactic-dose anticoagulation may be warranted. NSAIDs are an alternative for patients with no risk factors for VTE.

Guidelines recommend 45 days of anticoagulation, with prophylactic doses of fondaparinux as the preferred option.[60][62][65]​​​ Recommended alternatives include prophylactic- or intermediate-dose low molecular weight heparin, or oral rivaroxaban for patients who decline or are unable to use parenteral anticoagulation.[60][62]​​ Intermediate doses are larger than prophylactic doses, and smaller than treatment doses. The 2023 European Society for Vascular Surgery guideline on antithrombotic therapy recommends intermediate-dose LMWH, as data suggests it is more effective than prophylactic-dose LMWH at preventing recurrent events.[65]

Other options include unfractionated heparin (UFH) alone, or warfarin overlapped with 4 days of UFH or LMWH and continued for 45 days. These options are no longer commonly used in the US but may be indicated in rare circumstances (e.g., critically ill hospitalised patients). Use of UFH is supported by weak evidence.[70][74] Warfarin has largely been replaced by alternative options because it requires frequent monitoring and is associated with an increased risk of bleeding.[69]​

If the thrombus is within an axial superficial vein, close monitoring for propagation is warranted.

A thorough assessment of bleeding risk should be undertaken before prescribing an anticoagulant. Direct oral anticoagulants should be used with caution in patients with renal insufficiency; dose adjustment or an alternative treatment (LMWH, UFH, or warfarin) may be required.[69]​ Surveillance for heparin-induced thrombocytopenia may be necessary in some cases. 

Consult specialist or local protocols for guidance on dose.

Primary options

fondaparinux

Secondary options

rivaroxaban

OR

enoxaparin

OR

dalteparin

Tertiary options

heparin

OR

enoxaparin

or

dalteparin

or

heparin

-- AND --

warfarin

Consider – supportive therapy

Back
ACUTE
|
non-pregnant: SVT <5 cm in length within axial superficial vein or thrombus within tributary varicose veins only
Consider – 

supportive therapy

Additional treatment recommended for SOME patients in selected patient group

Compression stockings are usually prescribed for 10-14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings to help in the resolution of inflammation and superficial vein thrombosis (SVT), are recommended. They are put on in the morning before getting up and removed in the evening when going to bed.

Compression therapy has not been shown to prevent SVT extension or thromboembolic complications.

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index is <0.8. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

Local heat and leg elevation may help alleviate acute symptoms.

Ice may also be used instead of heat initially to decrease inflammation.

pregnant: SVT (any size) within axial or tributary vein

1st line – prophylactic anticoagulation

Back
ACUTE
|
pregnant: SVT (any size) within axial or tributary vein
1st line – 

prophylactic anticoagulation

Guidelines recommend anticoagulation for all pregnant women with superficial vein thrombosis (SVT), due to the persistent increased thrombotic risk throughout pregnancy and for at least 6 weeks postnatal.[83]​ Prophylactic- or intermediate-dose low molecular weight heparin is recommended, but the optimum duration of treatment is uncertain.​[62][83]​ Recommendations vary from a fixed period (1-6 weeks) to treatment for the remainder of pregnancy and 6 weeks postnatal for SVT that is bilateral, symptomatic, ≤5 cm from the deep venous system, or ≥5 cm in length.​[62][83]

The American Society of Hematology guideline suggests that the benefit of anticoagulation may be less for SVT that is more distal or less symptomatic and for patients who are needle averse.[83] If no treatment is administered, guidelines recommend clinical follow-up and repeat ultrasound within 7-10 days.[62]

Consult specialist or local protocols for guidance on dose.

Primary options

enoxaparin

OR

dalteparin

Consider – supportive care

Back
ACUTE
|
pregnant: SVT (any size) within axial or tributary vein
Consider – 

supportive care

Additional treatment recommended for SOME patients in selected patient group

Supportive care for superficial vein thrombosis (SVT) during pregnancy includes increased hydration (pregnancy has higher blood volume), ambulation, compression stockings, and local ice (acute SVT) or heat (subacute SVT, after the initial inflammation is starting to decrease).

Compression stockings are usually prescribed for 10-14 days. Short or long stretch elastic bandages in the acute phase to relieve pain, followed by compression stockings to help in the resolution of inflammation and SVT, are recommended. They are put on in the morning before getting up and removed in the evening when going to bed.

Compression therapy has not been shown to prevent SVT extension or thromboembolic complications.

Compression stockings should not be used where the systolic arterial pressure at the ankle is <80 mmHg or the ankle-brachial pressure index is <0.8. Other contraindications to the use of stockings include acute dermatitis, open wounds, and phlegmasia cerulea dolens. Caution is advised in patients with diabetes, neuropathy, skin sensitivities or allergies, and signs of infection.

ONGOING

incompetent saphenous vein with associated varicose veins or recurrent SVT

1st line – consider varicose vein procedure ± prophylactic anticoagulation

Back
ONGOING
|
incompetent saphenous vein with associated varicose veins or recurrent SVT
1st line – 

consider varicose vein procedure ± prophylactic anticoagulation

After the acute treatment of superficial vein thrombosis (SVT) in an incompetent saphenous vein with associated varicose veins or in the case of repeated episodes, consider referral for a varicose vein procedure, such as endovenous thermal or chemical ablation.[61]​ In patients with associated saphenous vein insufficiency, treatment of the refluxing axial superficial vein serves to prevent recurrence of SVT.

The workup would include a venous insufficiency ultrasound to evaluate the deep and superficial veins for evidence of reflux once the patient is out of the prothrombotic period.

Varicose vein surgical procedures should be done only after the acute SVT episode resolves to avoid thromboembolic complications induced by such procedures.[61]

Guidelines for varicose surgery should be followed.

Prophylactic low molecular weight heparin therapy may be considered at the time of surgery.[82]

Varicose vein procedures are elective and would not be considered during pregnancy.

Primary options

enoxaparin: prophylaxis: 40 mg subcutaneously once daily

OR

dalteparin: prophylaxis: 5000 units subcutaneously once daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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