Vessel

Superior Vena Cava Obstruction

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Superior Vena Cava Obstruction, Superior Caval Vein Obstruction, Superior Vena Cava Occlusion, Superior Vena Cava Syndrome

  • Pathophysiology
  1. Azygous vein may provide some collateral drainage
  2. Superior Vena Cava Obstruction to flow
    1. Vena cava thrombosis
    2. Mediastinal Mass gradually compresses superior vena cava, blocking entry into right atrium
      1. Results in retrograde flow and regional edema
  • Causes
  1. Malignancy
    1. Bronchogenic Carcinoma (80%)
    2. Malignant Lymphoma (15%)
    3. Metastatic Disease (to lung, mediastinum or lymph nodes)
      1. Breast adenocarcinoma
      2. Testicular seminoma
  2. Benign Disease (Rare)
    1. Mediastinal fibrosis
      1. Idiopathic
      2. Histoplasmosis
      3. Actinomycosis
      4. Tuberculosis
    2. Vena Cava thrombosis
      1. Idiopathic
      2. Behcet's Syndrome
      3. Polycythemia Vera
      4. Paroxysmal Nocturnal Hemoglobinuria
      5. Long-term venous catheters, shunts or Pacemakers
    3. Benign Mediastinal tumor
      1. Aortic aneurysm
      2. Dermoid tumor
      3. Goiter
      4. Sarcoidosis
  • Symptoms
  1. Dyspnea (50%)
  2. Neck and facial swelling (40%)
  3. Swelling of trunk and upper extremities (40%)
  4. Choking sensation
  5. Hoarseness
  6. Head fullness or pressure sensation
  7. Headache
    1. Common presenting complaint
    2. Secondary to Increased Intracranial Pressure
  8. Chest Pain
  9. Shoulder Pain
  10. Cough
  11. Lacrimation
  12. Dysphagia
  13. Visual changes
  14. Syncope
  • Signs
  1. Thoracic vein distention (65%)
  2. Neck vein distention (55%)
  3. Facial edema (55%)
  4. Tachypnea (40%)
  5. Plethora of the face and Cyanosis (15%)
  6. Edema of upper extremities (10%)
  7. Paralysis of Vocal Cords (3%)
  8. Horner's Syndrome (3%)
  9. Distended antecubital veins
  • Associated Conditions
  1. Spinal Cord compression
  • Radiology
  1. Chest XRay shows mass in 90%
    1. Right superior mediastinum (75%)
    2. Hilar Adenopathy (50%)
    3. Right Pleural Effusion (25%)
  2. Chest CT
  • Management
  1. Identify mass etiology
  2. Supportive care
    1. ABC Management
    2. Corticosteroids
    3. Diuretics
    4. Elevate the head of the bed
  3. Reduction in mass size
    1. Emergent Intervention Radiology
    2. Other modalities
      1. Radiation Therapy
      2. Chemotherapy
      3. Surgical decompression
  4. Consult Oncology and Cardiothoracic Surgery acutely
    1. Palliative CareConsultation once stabilized
  5. Consider Anticoagulation
  6. Intravenous stenting
    1. Common acute management
    2. Improvement is seen within days
    3. Effective even when tumor mass is not reducible
  • Prognosis
  1. Poor prognostic sign
    1. Predicts 90% mortality in 3 years
    2. Median survival: 6 months