Superior Vena Cava Syndrome

Introduction

Superior Vena Cava Syndrome is a common oncological complication which mostly occurs because of a tumour compressing the SVC. This causes poor venous return resulting in a collection of symptoms such as dyspnoea, oedema and plethora. Although rarely life-threatening, it can present with severe respiratory distress.

The majority of cases are due to malignancy however, there are non-malignant causes too. Of the malignant cases in adults, 75% are due to Lung cancer, while 10% is from lymphoma. These tumours tend to grow centrally and compress the thin-walled SVC.

Benign causes are less common and include luminal obstruction from pacemaker leads or catheter-related thrombosis. These causes will require different management including catheter removal and thrombolysis or anticoagulation.

Obstructing the SVC forces some blood to divert to 4 collateral venous pathways in order to return to the heart. The most important of these collaterals being the azygous venous system, located on either side of the vertebral column, which has many anastomoses with inferior vena cava.

Initial management should focus on symptomatic relief. This might include elevating the patient’s bed and prescribing an opioid for dyspnoea and pain. A trial of dexamethasone should be started to decrease the tumour mass by reducing associated inflammatory oedema.

Definitive management should be sought in the form of radiotherapy. Alternatively, endovascular stenting could be performed, in which a self-expanding or balloon-expandable stent is inserted into the SVC, usually via the femoral vein.

The onset of SVC syndrome can be slow or abrupt with the degree of obstruction correlating to the severity of symptoms. On history, patients often have dyspnoea, cough and chest pain. On physical exam, you might notice facial plethora and engorged veins in the neck and upper chest.

One particular examination to perform is Pemberton’s manoeuvre. This can be done by lifting the patient’s arms 180 degrees for 1 minute. This might result in more obvious facial oedema and plethora.

I remember this by thinking that you have to DRESS for success in SVC management.

You give patients dexamethasone, radiotherapy and endovascular stenting after Symptomatic management.

Dexamethasone

Radiotherapy

Endovascular Stenting

Symptomatic management

DRESS