MKSAP Quiz: Evaluation for right calf pain
A 24-year-old woman is evaluated for pain in the right calf since yesterday. She reports no shortness of breath, cough, or chest pain. Her medical history is unremarkable. Following a physical exam and ultrasound, what is the most appropriate management?
A 24-year-old woman is evaluated for pain in the right calf since yesterday. She reports no shortness of breath, cough, or chest pain. Her medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal. A tender venous cord is palpable in the right calf. No asymmetry in calf diameter is noted.
Duplex ultrasound of the right leg shows an acute thrombosis of the right lesser saphenous vein that is 7 cm in length.
Which of the following is the most appropriate management?
A. Anticoagulation for 3 months
B. Anticoagulation for 6 weeks
C. Vein ligation
D. Observation with ultrasound surveillance
MKSAP Answer and Critique
The correct answer is B. Anticoagulation for 6 weeks. This content is available to MKSAP 19 subscribers as Question 67 in the Hematology section. More information about MKSAP is available online.
The most appropriate management is anticoagulation for 6 weeks to treat a superficial vein thrombosis (SVT) (Option B). SVT often affects the lower extremities and is thought to account for 10% of lower extremity thromboses. The lesser saphenous vein is a distal superficial vein. Treatment is indicated for SVT when the thrombus is 5 cm or greater in length or is close to the deep venous system or if other thrombophilic risk factors are present. This patient's thrombus length is 7 cm, so anticoagulation for 6 weeks is indicated.
An anticoagulant therapy duration of 3 to 6 months is appropriate management of an acute proximal deep venous thrombosis (DVT) that is provoked by reversible risk factors (Option A). SVT, provoked or unprovoked, can be treated with only 6 weeks of anticoagulation.
Vein ligation might be considered for patients at higher risk who have an absolute contraindication to anticoagulation to prevent propagation of the thrombus into the deep venous system (Option C). Vein ligation is not part of routine care. In this patient, anticoagulation is the preferred therapy.
Observation would be an appropriate management option for a superficial vein thrombosis without high-risk features (Option D). Patients with low-risk lower extremity SVT can be managed conservatively with warm compresses, analgesics, and NSAIDs. Compression stockings may hasten the resolution of the thrombus. Follow-up should be scheduled in 1 week to ensure symptom resolution. If symptoms persist or worsen, repeat duplex ultrasonography should be performed to evaluate for extension of the thrombus. If repeat ultrasound shows thrombus extension, anticoagulation would then be indicated.
Key Points
- Six weeks of anticoagulation is indicated for superficial vein thrombosis when the thrombus is 5 cm or greater in length or is close to the deep venous system or when other thrombophilic risk factors present.
- For patients with low-risk superficial vein thrombosis, observation with follow-up in 1 week to ensure symptom resolution is reasonable; if symptoms persist or worsen, repeat duplex ultrasonography should be performed.