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

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.