Snapshot A 60-year-old woman presents to her physician’s office for a painful cord-like rash on her left calf. She reports that it is red, painful to the touch, and seems like a varicose vein. She has had multiple varicose veins in the past but nothing as painful or red as this lesion. She reports that she is currently undergoing estrogen replacement therapy, as menopause has been a difficult transition. On physical exam, there is erythema and tenderness along the cord-like lesion, which feels thick and hardened on palpation. She is counseled on the benefits of compression therapy. Introduction Clinical definition a thrombotic disorder characterized by thrombi and inflammation (phlebitis) in the superficial veins Epidemiology demographics women > men more common in adults location most commonly in the lower extremities can also occur at sites of trauma (e.g., sites of intravenous catheters) risk factors venous stasis varicose veins hypercoagulable state pregnancy high-dose estrogen therapy malignancy immobilization Pathogenesis endothelial injury can trigger thrombus formation and inflammatory response Associated conditions migratory thrombophlebitis (Trousseau syndrome) deep venous thrombosis Buerger disease Prognosis self-limited, but can recur frequently Presentation Symptoms pain of the involved site Physical exam erythema and edema along the vein tenderness along the vein palpable thickened or thrombosed vein visibly distended veins while distended veins below the ankle are normal, it is suggestive of pathology if the distended veins are above the ankle Imaging Duplex ultrasound indications a confirmatory imaging test to evaluate for deep venous thrombosis findings impaired blood flow lack of compressibility of the vein Studies Labs D-dimer is not useful in this disease Making the diagnosis based on clinical presentation Differential Deep venous thrombosis distinguishing factor thrombosed vein is typically not palpable Treatment Management approach pain management prevent extension into deep venous system Conservative compression indication for all patients Medical anticoagulation indication not usually indicated unless process involves deep venous system drugs low molecular weight heparin fondaparinux nonsteroidal anti-inflammatory drugs (NSAIDs) indication pain management only in patients who did not undergo anticoagulation Complications Progression to deep venous system pulmonary embolism deep venous thrombosis