Unusual cause of superior vena cava syndrome diagnosed with transesophageal echocardiography

Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography

BACKGROUND

Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor.

CASE SUMMARY

A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief.

DISCUSSION

This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.

LEARNING POINTS

Iatrogenic Superior Vena Cava Syndrome after Cardiopulmonary Bypass Diagnosed by Intraoperative Echocardiography

A 73-year-old female patient presented for mitral valve replacement and coronary artery bypass grafting secondary to multivessel coronary disease and severe mitral valve regurgitation with moderate stenosis. After bypass, the patient developed refractory hypotension with decreased biventricular volume and elevated central venous pressure (CVP). Transesophageal echocardiography (TEE) was utilized to make the diagnosis of acute intraoperative superior vena cava (SVC) syndrome. The SVC cannulation site was revised, resulting in resolution of the hypotension and a decrease in the CVP. Intraoperative TEE was vital in recognizing, managing, and ultimately repairing the acute intraoperative SVC stenosis.

Aortic valve endocarditis with root abscess causing superior vena cava obstruction: a case report

Background

To our knowledge, we report the first case of endocarditis with root abscess causing compressive superior vena cava (SVC) obstruction.

Case summary

An 84-year-old gentleman with previous tissue aortic valve replacement presented with fevers and systemic upset. Blood cultures grew Streptococcus anginosus and transoesophageal echocardiogram identified prosthetic valve vegetations with an associated root abscess. Antibiotics were commenced and referral made for surgical consideration. Several days into treatment the patient developed clinical signs of SVC obstruction and computed tomography demonstrated an enlarging root abscess with SVC compression. The patient was discussed with local cardiothoracic centres, but surgery was not an option primarily due to abscess size and vascular involvement. Priority moved from active to palliative treatment given no improvement with antibiotics, unsuitability for surgery, and patient discomfort. Within several weeks, symptoms/signs of SVC obstruction actually improved, likely due to collateral venous circulation formation and the patient was discharged home with palliative care input.

Discussion

There are previous reports of SVC obstruction related to infected SVC thrombus, indwelling intravascular devices, and para-aortic abscess, but none related to infective endocarditis. Streptococcus anginosus endocarditis is rare but often associated with abscess formation, and male gender, increasing age, and previous surgery are recognized risk factors.

A case requiring tracheal stenting due to superior vena cava syndrome developing after craniotomy

We report a patient who developed sustained hypotension during craniotomy; further, owing to a mediastinal mass, critical tracheal stenosis and brain edema were observed after craniotomy, despite the absence of preoperative symptomatic superior vena cava (SVC) syndrome. A 62-year-old man underwent removal of a suspected metastatic brain tumor. The main brain tumor was speculated to be a metastatic tumor from lung cancer. A subsequent chest CT revealed a large solid tumor in the mediastinum. The maximum reduction in the cross-sectional area of the trachea was estimated to be 50 %. In addition, bilateral innominate veins were completely obstructed, and the superior vena cava was involved in the mass and was completely compressed. The patient did not show any cardiopulmonary symptoms or upper body edema. Intravenous lines were secured at the right extremity. General anesthesia was induced without any complications and was maintained with sevoflurane, remifentanil, and rocuronium. During the surgery, hemodynamic status fluctuated and was unstable. To maintain systolic blood pressure, continuous, massive infusion of noradrenaline was required. After the surgery, the patient was turned to the supine position. Massive facial edema was apparent. In addition, the bilateral upper extremities were significantly swollen. Despite the removal of the main lesion, brain edema was still observed on head CT. Chest CT revealed that the maximum reduction in the cross-sectional area of the trachea was estimated to be >90 %, which necessitated mechanical ventilation with tracheal intubation. On the day following craniotomy, tracheal stenting was performed uneventfully. The patient’s trachea was finally extubated, and his respiratory condition did not deteriorate. Although he did not develop SVC syndrome, the patient died from asphyxiation after coughing up blood at home 5 months after the procedure. It was suggested that fluid infusion from the upper extremities owing to the mediastinal tumor caused critical SVC syndrome.

Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass

Anesthetic management of superior vena cava syndrome carries a possible risk of life-threatening complications such as cardiovascular collapse and complete airway obstruction during anesthesia. Superior vena cava syndrome results from the enlargement of a mediastinal mass and consequent compression of mediastinal structures resulting in impaired blood flow from superior vena cava to the right atrium and venous congestion of face and upper extremity. We report the successful anesthetic management of a 42-year-old man with superior vena cava syndrome posted for cervical lymph node biopsy.

A conventional multimodality imaging cascade to detect a superior vena cava obstruction

Iatrogenic injuries of the superior vena cava (SVC) following surgical or endovascular treatments are rare but challenging complications and require prompt diagnosis and appropriate treatment. The additional diagnostic value of venography, contrast-enhanced computed tomography, and magnetic resonance imaging has been widely assessed in the clinical setting of the SVC obstruction, whereas the role of conventional transoesophageal echocardiography (TEE) is still uncertain. A 43-year-old female patient was admitted to the echocardiography laboratory because of a superior vena cava syndrome (SVCS) following a balloon SVC venoplasty with stent implantation. A standard transoesophageal echocardiography examination clearly detected the SVC obstruction on previously implanted stents. We found that fundamental steps of early diagnosis of SVCS would benefit from standard TEE.