Superior vena cava obstruction

By Alex Yartsev - 11/07/2015

This came up in Question 25 from the second paper of 2005.

Generally speaking - on the basis of statistics - the cause of obstruction is almost invariably malignant. The mean life expectancy in these people is about 6 months even with treatment, but it can be variable depending on precisely which malignancy is involved.

Causes of SVC Obstruction
Type of SVC obstruction	Aetiology	Diagnosis	Management
Malignant	Malignant mass in thoracic inlet	History (eg. smoking) CT MRI CXR	Surgical excision SVC stenting by interventional radiology Dexamethasone Radiation therapy
Non-malignant	Tuberculosis	Suspicious history, CT, CXR, aspiration and AFB/ZN stain/PCR of the contents	Specific antituberculosis therapy Surgical relief of obstruction SVC stenting by interventional radiology
	Abscess	CT, CXR, aspiration and gram stain / culture of the contents	Surgical drainage Appropriate antibiotics
	Goitre	CXR, CT, TFTs, biopsy of the mass	Surgical excision Thyroid-suppressing medication eg. carbimazole SVC stenting by interventional radiology
	Thrombus	History of IJ CVC CT with contrast, ultrasound	Antioagulation; clot retrieval by interventinal radiology procedure, or surgical embolectomy
	Fibrosing mediastinitis	CT; History of mediastinitis or mediastinal radiotherapy	Surgical relief of obstruction SVC stenting by interventional radiology
	Aortic aneurysm	Ct with contrast; TOE	Surgical management of aneurysm; SVC stenting by interventional radiology

Clinical features of SVC obstruction:

Dyspnoea
Cyanosis
Facial swelling, particularly when supine
Venous distension of the neck and upper limbs
Swelling of one or both arms
Dysphagia

"Pemberton's sign" - worsening clinical signs when the arms are elevated

Generic management strategies

Definitive management:

Surgical relief of obstruction:
- Debulking excision of the offending mass
- Bypass of the obstructed segment with a saphenous vein graft
- Reconstruction of the SVC (periperative mortality is ~ 5%)
Stent insertion (endoluminal by interventional radiology) - the disadvantage of this is the need for ongoing anticoagulation, ideally with both antiplatelets and warfarin or LMW heparin.

Supportive and palliative management

Palliative radiotherapy
Palliative chemotherapy
Dexamethasone

References

MAURIEMARKMAN, MD. "Diagnosis and management of superior vena cava syndrome." Cleveland Clinic journal of medicine 66.1 (1999): 59.

Yahalom, Joachim. "Superior vena cava syndrome." REVISIONES EN CANCER 15.1 (2001): 15-25.

Rice, Todd W., R. Michael Rodriguez, and Richard W. Light. "The superior vena cava syndrome: clinical characteristics and evolving etiology." Medicine 85.1 (2006): 37-42.

Anders, H., and C. Keller. "Pemberton's maneuver-a clinical test for latent superior vena cava syndrome caused by a substernal mass." European journal of medical research 2.11 (1997): 488-490.

Asseff, David, et al. "Immediate Postoperative Percutaneous Stenting of Superior Vena Cava Obstruction Following Heart Transplantation in Adult Patients with Pacemaker Leads." Journal of cardiac surgery 29.5 (2014): 733-736.

Steel, Christopher J., et al. "Superior Vena Cava Syndrome: A Multimodality Approach to Diagnosis and Treatment." Contemporary Diagnostic Radiology36.18 (2013): 1-5.

Hall, W. A., et al. "A Comparison of Palliative Inpatient Management Strategies for Cancer-Related Superior Vena Cava Obstruction." International Journal of Radiation Oncology• Biology• Physics 90.1 (2014): S80-S81.

De Raet, Jan M., et al. "Surgical management of superior vena cava syndrome after failed endovascular stenting." Interactive cardiovascular and thoracic surgery 15.5 (2012): 915-917.

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