Superior vena cava syndrome: Difference between revisions

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==Background==
==Background==
#External compression by extrinsic malignant mass causes majority of cases
*External compression by extrinsic malignant mass causes majority of cases
#Thrombus in SVC from indwelling catheter/pacemaker is increasingly more common as cause
*Thrombus in SVC from indwelling catheter/pacemaker is increasingly more common as cause
#Infection
*Infection
#Rarely constitutes an emergency
*Rarely constitutes an emergency
##Gradual process; collaterals dilate to compensate for the impaired flow
**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
**Exception is neurologic abnormalities due to increased ICP, laryngeal edema causing stridor, decreased cardiac output
#Risk Factors:
 
##Lung Cancer
===Risk Factors===
##Lymphoma
*Lung Cancer
##Indwelling vascular catheters
*Lymphoma
*Indwelling vascular catheters (increasing incidence)
*Thrombotic coagulopathy
*Goiter
*TB
*Radiation
*Pericardial constriction


==Clinical Features==
==Clinical Features==
#Facial swelling
*[[Facial swelling]]
#Dyspnea
**Worse in morning, gets better as day progresses
#Cough
*[[Headache]]
#Arm swelling
*[[Cyanosis]]
#Distended neck/chest wall veins
*[[Dyspnea]]
#Neurologic abnormalities (rare)
*[[Cough]]
##Visual changes
*[[Arm swelling]]
##Dizziness
*Distended neck/chest wall veins
##Confusion
*Telangiectasia
##Seizure
*Neurologic abnormalities (rare)
**Visual changes
**[[Dizziness]]
**Confusion
**[[Seizure]]
**[[Syncope]]
**[[Papilledema]] and [[elevated ICP]]
 
==Differential Diagnosis==
{{Facial swelling DDX}}
 
{{Oncologic emergencies DDX}}
 
==Evaluation==
[[File:SVC_syndrome.jpg|thumb|CT chest showing right lung tumor compressing SVC]]
*CT with IV contrast
**Recommended imaging modality (assesses patency of the SVC, evaluate etiology mass vs. thrombus)
*[[CXR]]
**Shows mediastinal mass or paranchymal lung mass (10% of patients)


==Diagnosis==
==Management==
#CT w/ IV contrast
*Elevate head of bed
##Recommended imaging modality (assesses patency of the SVC, evaluate etiology mass vs. thrombus)
*Assess for and treat [[elevated intracranial pressure]]
#CXR
*Use IVs placed in lower extremities to avoid further SVC venous congestion<ref>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.</ref>
##Shows mediastinal mass or paranchymal lung mass (10% of pts)
*Corticosteroids and loop diuretics have questionable efficacy and should be held until ordered by admitting team<ref>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.</ref>
*Intravascular stent, consult IR
*If malignancy
**Mediastinal radiation, consult oncology/radiation oncology
*If thrombus
**Anticoagulation, catheter removal, consider thrombolytics


==Treatment==
==Disposition==
#Elevate head of bed
*Admit to ICU, with plan for airway monitoring and tissue biopsy
#Corticosteroids and Loop diuretics have questionable efficacy and should be held until ordered by admitting team<ref>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.</ref>
#Intravascular stent
#If malignancy
##Mediastinal radiation
#If thrombus
##Anticoagulation, catheter removal, consider thrombolytics


==Source==
==References==
<references/>
<references/>
Tintinalli, Emedicine, Rosen's


[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Revision as of 19:40, 28 April 2019

Background

  • External compression by extrinsic malignant mass causes majority of cases
  • Thrombus in SVC from indwelling catheter/pacemaker is increasingly more common as cause
  • Infection
  • 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)
  • Thrombotic coagulopathy
  • Goiter
  • TB
  • Radiation
  • Pericardial constriction

Clinical Features

Differential Diagnosis

Facial Swelling

Oncologic Emergencies

Related to Local Tumor Effects

Related to Biochemical Derangement

Related to Hematologic Derangement

Related to Therapy

Evaluation

CT chest showing right lung tumor compressing SVC
  • CT with IV contrast
    • Recommended imaging modality (assesses patency of the SVC, evaluate etiology mass vs. thrombus)
  • CXR
    • Shows mediastinal mass or paranchymal 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[1]
  • Corticosteroids and loop diuretics have questionable efficacy and should be held until ordered by admitting team[2]
  • Intravascular stent, consult IR
  • If malignancy
    • Mediastinal radiation, consult oncology/radiation oncology
  • If thrombus
    • Anticoagulation, catheter removal, consider thrombolytics

Disposition

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

References

  1. 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.
  2. 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.