Superior vena cava syndrome: Difference between revisions
Neil.m.young (talk | contribs) No edit summary |
|||
| (24 intermediate revisions by 8 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
[[File:Gray505.png|thumb|SVC anatomy.]] | |||
*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<ref> Nickloes TA, Lopez Rowe V, Kallab AM, Dunlap AB (28 March 2018). "Superior Vena Cava Syndrome". ''Medscape''</ref> | |||
*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]], [[shock|decreased cardiac output]] | |||
===Risk Factors=== | |||
*Lung Cancer | |||
*[[Lymphoma]] | |||
*Indwelling vascular catheters (increasing incidence) | |||
*Thrombophilia | |||
*[[thyroid|Goiter]] | |||
*[[TB]] | |||
*Radiation | |||
*Pericardial constriction | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:PMC4962438 12886 2016 301 Fig1 HTML.png|thumb|SVC syndrome with classic symptoms, including obvious face, neck, and upper trunk swelling.]] | |||
*[[Facial swelling]] | |||
**Worse in morning, gets better as day progresses | |||
*[[Headache]] | |||
*[[Cyanosis]] | |||
*[[Dyspnea]] | |||
*[[Cough]] | |||
*[[Arm swelling]] | |||
*Distended neck/chest wall veins | |||
*Telangiectasia | |||
*Neurologic abnormalities (rare) | |||
**[[visual disturbances|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 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<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> | |||
*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]] | |||
== | ==Disposition== | ||
*Admit to ICU, with plan for airway monitoring and tissue biopsy | |||
== | ==References== | ||
<references/> | |||
[[Category:Heme/Onc]] | [[Category:Heme/Onc]] | ||
Latest revision as of 04:47, 8 January 2022
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
- Facial swelling
- Worse in morning, gets better as day progresses
- Headache
- Cyanosis
- Dyspnea
- Cough
- Arm swelling
- Distended neck/chest wall veins
- Telangiectasia
- Neurologic abnormalities (rare)
Differential Diagnosis
Facial Swelling
- Buccal space infections
- Dental problems
- Canine space infection
- Facial cellulitis
- Herpes zoster
- Masticator space infections
- Maxillofacial trauma
- Neoplasm
- Parapharyngeal space infection
- Salivary gland diagnoses
- Parotitis
- Ranula
- Sialoadenitis
- Sialolithiasis
- Superior vena cava syndrome
Oncologic Emergencies
Related to Local Tumor Effects
- Malignant airway obstruction
- Bone metastases and pathologic fractures
- Malignant spinal cord compression
- Malignant Pericardial Effusion and Tamponade
- Superior vena cava syndrome
Related to Biochemical Derangement
- Hypercalcemia of malignancy
- Hyponatremia due to SIADH
- Adrenal insufficiency
- Tumor lysis syndrome
- Carcinoid syndrome
Related to Hematologic Derangement
Related to Therapy
- Chemotherapy-induced nausea and vomiting
- Cytokine release syndrome
- Chemotherapeutic drug extravasation
- Differentiation syndrome (retinoic acid syndrome) in APML
- Stem cell transplant complications
- Catheter-related complications
- Tunnel infection
- Exit site infection
- CVC obstruction (intraluminal or catheter tip thrombosis)
- Catheter-related venous thrombosis
- Fracture of catheter lumen
- Oncologic therapy related adverse events
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
- Anticoagulation, catheter removal, consider thrombolytics
Disposition
- Admit to ICU, with plan for airway monitoring and tissue biopsy
References
- ↑ Nickloes TA, Lopez Rowe V, Kallab AM, Dunlap AB (28 March 2018). "Superior Vena Cava Syndrome". Medscape
- ↑ 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.
- ↑ 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.