Diagnostik und Therapie der Thrombophlebitis unter besonderer Berücksichtigung niedermolekularer Heparine

 

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Zusammenfassung

Die klinische Diagnose der oberflächlichen Thrombophlebitis ist charakterisiert durch das Auftreten von schmerzhaften und entzündeten Strängen im Bereich von oberflächlichen Venen und Varizen. Eine Duplexsonographie wird empfohlen, um eine asymptomatische tiefe Venenthrombose auszuschließen, die in ca. 20% vorliegen kann, und um potentielle Eintrittspforten des thrombotischen Prozesses in tiefe Venen (z. B. Mündung von Vena saphena magna und parva) abzuklären. Die klassische Behandlung basiert auf einer festen Kompression sowie Gehübungen. Inzisionen mit Expression von Gerinnseln sowie entzündungshemmende Medikamente können Schmerzen und Entzündung lindern. Wenn die Phlebitis auch den Oberschenkel und besonders die proximalen Anteile der Vena saphena magna betrifft, kann eine Mündungsligatur und eine lokale Thrombektomie überlegt werden, bevorzugt unter ambulanten Bedingungen. Neue Daten einer randomisierten kontrollierten Studie beweisen die Wirksamkeit von unfraktioniertem Heparin in der Dosierung von zweimal 12 500 I.E. s. c. bei dieser Indikation.

Aufgrund einer weiteren randomisierten kontrollierten Studie kann niedermolekulares Heparin (NMH) die Entwicklung von thromboembolischen Komplikationen und die relativ häufige Ausbreitung der Thromben in den oberflächlichen Venen verzögern. Therapeutische Dosen scheinen effektiver zu sein als prophylaktische. Während die herkömmliche Behandlung mit Kompression und Gehübungen für die meisten Fälle ausreicht, wird die zusätzliche Gabe von niedermolekularen Heparinen bei erhöhtem Thromboembolierisiko und bei Oberschenkelmitbeteiligung empfohlen. Die wenigen Studien berichten von einer Behandlungszeit von 6-12 Tagen. Mehr Studien speziell im Hinblick auf Indikation, Dosierung und Therapiedauer von NMH sind erforderlich, um klare Therapierichtlinien geben zu können.

Summary

The clinical diagnosis of superficial thrombophlebitis is characterized by the occurrence of painful and inflamed cords along superficial veins and varices. Duplex sonography is recommended to rule out asymptomatic deep vein thrombosis which may be present in about 20% and to check potential sources of entrance of the thrombotic process into deep veins, like the junctions of great and small saphenous veins.

Classic therapy is based on firm compression therapy and walking exercises. Incisions with expression of clots and anti-inflammatory drugs may reduce pain and inflammation. When phlebitis involves also the thigh and especially the proximal part of the great saphenous vein surgical ligation of the junction and local thrombectomy can be considered, preferably on an outpatient basis. Recent data from one randomised controlled trial demonstrate the efficacy of unfractionated heparin in a dose of 12 500 I.U. s. c. twice a day in this indication. According to another randomised controlled trial low molecular weight heparin (LMWH) may reduce the development of thromboembolic complications and also the relatively frequent extension of the thrombi in the superficial veins. Therapeutic doses seem to be more effective than prophylactic doses. While conventional therapy with compression and walking is sufficient for the majority of cases, the additional use of low molecular heparin is recommended in increased thromboembolic risk and when the thigh is involved. In the few studies available treatment time of 6-12 days is reported. More studies with special focus on indication, dosage and duration of therapy with LMWH are needed for the recommendation of clear therapeutic guidelines.

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