Superior vena cava syndrome

Background

  • External compression by extrinsic malignant mass causes majority of cases
  • Thrombus in SVC from indwelling catheter/pacemaker is increasingly more common as cause
  • Other causes include benign tumors, aortic aneurysm, infections, and fibrosing mediastinitis[1]
  • Rarely constitutes an emergency
    • Gradual process; collaterals dilate to compensate for the impaired flow
    • Exception is neurologic abnormalities due to increased ICP, laryngeal edema causing stridor, decreased cardiac output

Risk Factors

  • Lung Cancer
  • Lymphoma
  • Indwelling vascular catheters (increasing incidence)
  • Thrombophilia
  • Goiter
  • TB
  • Radiation
  • Pericardial constriction

Clinical Features

Differential Diagnosis

Facial Swelling

Oncologic Emergencies

Evaluation

  • CT with IV contrast
    • Recommended imaging modality (assesses patency of the SVC, evaluate etiology mass vs. thrombus)
  • CXR
    • Shows mediastinal mass or parenchymal lung mass (10% of patients)

Management

  • Elevate head of bed
  • Assess for and treat elevated intracranial pressure
  • Use IVs placed in lower extremities to avoid further SVC venous congestion[2]
  • Corticosteroids and loop diuretics have questionable efficacy and should be held until ordered by admitting team[3]
  • Intravascular stent, consult IR
  • If malignancy
    • Mediastinal radiation, consult oncology/radiation oncology
  • If thrombus

Disposition

  • Admit to ICU, with plan for airway monitoring and tissue biopsy

References

  1. Nickloes TA, Lopez Rowe V, Kallab AM, Dunlap AB (28 March 2018). "Superior Vena Cava Syndrome". Medscape
  2. Chaudhary K, Gupta A, Wadhawan S, Jain D, Bhadoria P. Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2016 Jul 19];28:242-6. Available from: http://www.joacp.org/text.asp?2012/28/2/242/94910.
  3. McCurdy M et al. Oncologic emergencies, part I: spinal cord compression, superior vena cava syndrome, and pericardial effusion. Emergency Medicine Practice. 2010; 12(2):7-10.
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