Superior vena caval obstruction

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 876 times

231 Superior vena caval obstruction

Instruction

Look at this patient.

Salient features

History

• Headache

• Dysphagia

• Dyspnoea

• Wheezes

• Blackouts

• Oedema of the face.

Examination

• Tortuous, visible and dilated veins on the chest wall and neck (Fig. 231.1).

• The neck veins are non-pulsatile

• The face may be plethoric and suffused. The patient may be short of breath

• Look for signs of Horner syndrome and for radiation marks

• Tell the examiner that you would like to examine for signs of bronchogenic carcinoma, i.e. clubbing, tar staining, lymph nodes and chest signs.

image

Fig. 231.1 Superior vena cava obstruction in bronchial carcinoma. Note the swelling of the face and neck and the development of collateral circulation in the veins of the chest wall.

(With permission from Forbes, Jackson 2003.)

Diagnosis

This patient has superior vena caval obstruction (lesion), which is usually caused by bronchogenic carcinoma (aetiology), and is tachypnoeic at rest (functional status).

Questions

What are the causes of superior vena caval obstruction?

• Bronchogenic carcinoma is the commonest cause (in 70%)

• Lymphoma: in young adults

• Other causes:

• Aortic aneurysm
• Mediastinal goitre
• Mediastinal fibrosis (from methysergide, histoplasmosis or TB)
• Constrictive pericarditis.

How would you manage this patient?

This condition is a medical emergency and an urgent CT scan or MRI of the chest should be requested (Chest 1993;103(suppl 4):394S). Emergency treatment consists of:

• intravenous furosemide to relieve the oedematous component of vena caval compression

• intravenous anticancer chemotherapy, e.g. cyclophosphamide

• mediastinal irradiation within 24 h (the majority of the tumour types causing the superior vena cava syndrome are sensitive to radiotherapy, but tissue diagnosis is required prior to radiotherapy)

• more recently, expandable metal stents have been used to relieve the obstruction (Fig. 231.2)

• mechanical thrombectomy with an Amplatz thrombectomy device (BMJ 1994;308:1697–9).

image

Fig. 231.2 Superior vena cava venogram. (A) Venogram made after a right femoral venous approach, with insertion of a catheter (thin arrow) into the left brachiocephalic vein; there is severe stenosis (thick arrow). (B) A double-Z stent placed in the portion of the stenotic vena cava (arrows) immediate restored normal blood flow.

(With permission from Walsh 2008.)

How are the venous collaterals formed?

Blood flows through a collateral vascular network to the lower body and the inferior vena cava or the azygos vein when the superior vena cava is obstructed. It usually takes several weeks for these venous collaterals to dilate sufficiently to accommodate the blood flow. The cervical venous pressure is usually increased to 20–40 mmHg (normal range, 2–8 mmHg). The severity of the symptoms depends on the degree of narrowing of the superior vena cava and the rapidity of the onset of the narrowing.

Obstruction of the superior vena cava was first described in 1757 by William Hunter in a case of syphilitic aortic aneurysm.

Share this:

Related posts:

Default ThumbnailSixth cranial nerve palsy Osteoarthrosis Optic atrophy Default ThumbnailHepatomegaly Carotid artery aneurysm Felty’s syndrome