Superior Vena Cava Syndrome

An overview of downhill esophageal varices: a challenge for medical practice

OBJECTIVES

Unlike the commonly seen uphill esophageal varices in clinical practice, downhill esophageal varices are caused by obstruction of the superior vena cava and azygous venous system. The predominant causes of downhill esophageal varices are hemodialysis in end-stage renal disease patients and mediastinal malignancies. The cornerstone of the treatment for downhill esophageal varices is to address the underlying primary causes. Without this, patients may suffer from recurrent bleeding, and the bleeding can be fatal.

METHODS

This review is primarily summarized through previous case reports. Meanwhile, it emphasizes the significance of case reports.

RESULTS

Clinicians should be conscious that esophageal varices are not necessarily caused by liver cirrhosis or non-cirrhotic portal hypertension.

CONCLUSIONS

Specifically, when varices are only observed in the upper and middle esophagus, and the patient presents with evidence of superior vena cava obstruction, clinicians should be particularly vigilant for downhill esophageal varices. Moreover, a thorough investigation and definitive treatment of the underlying primary causes should be implemented.

Percutaneous stenting as treatment for chylothorax from superior vena cava syndrome: A case report

Superior vena cava syndrome is a condition that results from obstruction of the superior vena cava, the etiology of which can be benign or malignant. The impaired venous return can cause facial and upper extremity swelling, dyspnea, and neurologic symptoms. Chylothorax is a rare complication of superior vena cava syndrome. We report a case of a 69-year-old male with end-stage renal disease, who developed both a chylothorax and a contralateral simple pleural effusion secondary to superior vena cava syndrome. He was successfully treated with percutaneous endovascular stenting.

Superior Vena Cava Decompression After Complicated Stent Placement for Innominate Vein Obstruction in a VVI-ICD Patient

OBJECTIVES

This report discusses the challenges and strategies involved in managing venous stenosis secondary to pacing or defibrillator leads, focusing on endovascular treatment options and procedural considerations.

KEY PROCEDURAL STEPS

Crucial steps of the procedure include thorough preprocedural planning, obtaining multisite venous access for optimal angiographic visualization, wiring through the stent using a percutaneous coronary intervention wire supported by a microcatheter and guiding catheter, confirming true lumen and intraluminal wire passage, and progressive ballooning using high-pressure balloons and kissing balloon technique.

POTENTIAL PITFALLS

Procedural complications include crushing of the pacing leads within the stent, incomplete stent expansion, and aggravation of existing stenosis. Ensuring correct wire trajectory and using multiple imaging modalities are critical to avoiding these issues.

TAKE-HOME MESSAGE

Venous stenosis related to pacing leads requires a multidisciplinary approach, with careful preprocedural planning and meticulous technique.

The Aftermath of Obstruction: Decoding Collateral Pathways in Superior Vena Cava Syndrome

Superior vena cava (SVC) syndrome (SVCS) is any occlusion of the SVC, resulting in venous blood backup. Common causes of SVCS include mediastinal tumors and, less frequently, implanted venous devices. Understanding collateral venous formation in SVCS is crucial for identifying alternative pathways for venous return and alleviating symptoms of venous obstruction. The SVC, formed by the anastomosis of the right and left brachiocephalic veins, drains blood from structures above the diaphragm into the right atrium. Here, we provide a unique postmortem analysis of SVCS and collateral venous formation to support clinical identification and treatment. A 48-year-old cadaver with a limited medical history of metastatic rectal cancer was dissected in an anatomy course. The SVC was observed to be occluded in its entirety. The likely cause of SVCS was mediastinal tumors. Vessel dilation was observed within the azygos system, intercostal, right thoracic-epigastric, inferior epigastric, and internal thoracic veins. Collateral venous formation was found by way of the azygos and hemiazygos veins, which joined inferiorly to form a single vessel draining into the inferior vena cava (IVC), and multiple left intercostal veins formed single communications with the azygos vein. Recognizing this complex anatomy and patterns of the azygos venous system is crucial in understanding alternative blood flow pathways in cases of SVCS. Variations in this system can form critical venous collaterals, bypassing obstructions and relieving venous congestion. Although visualizing these collateral networks on imaging can be challenging, postmortem gross findings offer crucial insights into collateral formations and potential patterns in SVCS presentation. Ultimately, detailed understanding and identification of azygos venous patterns improve patient safety, support accurate diagnosis, and optimize treatment outcomes across a range of medical and surgical disciplines.

Clinical Approach to Central Airway Obstruction in Adult Patients: Perioperative Focus on Causes and Management Including Tracheobronchial Stenting

Central airway obstruction (CAO) is a life-threatening condition associated with poor prognosis. Therapeutic bronchoscopy along with systemic therapies significantly improve survival and quality of life in patients with symptomatic benign and malignant CAO. Endoluminal therapies and tracheobronchial stenting may be used, and a multidisciplinary approach is essential for holistic management of CAO. Perioperative planning and evaluation, as well as attention to intraoperative and postoperative management are key to optimal outcomes. This review provides an overview of the etiology and clinical approach to CAO, perioperative considerations for endoluminal therapies and tracheobronchial stenting, perioperative evaluation and preparation for therapeutic bronchoscopy, and management of operative and postoperative challenges in CAO.

Percutaneous access to the right atrium through the site of superior vena cava occlusion to re-catheterization for a maintenance hemodialysis patient with central venous obstruction

Central venous catheters are commonly used for hemodialysis, but prolonged use can lead to complications such as central venous occlusion, resulting in catheter-dependent dialysis patients being unable to undergo dialysis. Herein, we present the case of a 57-year-old female patient who had been dependent on catheter-based hemodialysis for 8 years. Her tunneled central venous catheter (TCC) had been replaced three times and she had developed severe central venous occlusion. For this patient, a procedure was performed involving a percutaneous puncture through the site of superior vena cava occlusion to gain access to the right atrium. The intervention utilized multiple surgical instruments, including a transseptal needle in combination with the stiffening cannula from the RUPS-100 Suite, to facilitate re-catheterization for maintenance hemodialysis. We discuss the feasibility of such procedures as a last-resort option while emphasizing the associated risks.

Long-Term Complications Related to Cardiac Implantable Electronic Devices

Cardiac implantable electronic devices (CIEDs) are commonly used for a number of cardiac-related conditions, and it is estimated that over 300,000 CIEDs are placed annually in the US. With advances in technology surrounding these devices and expanding indications, CIEDs can remain implanted in patients for long periods of time. Although the safety profile of these devices has improved over time, both the incidence and prevalence of long-term complications are expected to increase. This review highlights pertinent long-term complications of CIEDs, including lead-related issues, device-related arrhythmias, inappropriate device therapies, and device-related infections. We also explore key clinical aspects of each complication, including common presentations, patient-specific and non-modifiable risk factors, diagnostic evaluation, and recommended management strategies. Our goal is to help spread awareness of CIED-related complications and to empower physicians to manage them effectively.

Bicaval thrombosis and systemic-to-pulmonary venous shunting: A case report and systematic review of the literature

Systemic-to-pulmonary venous shunts (SPVSs) in the setting of combined superior and inferior venae cavae occlusion are exceedingly rare. A 52-year-old female with antiphospholipid syndrome and venous thromboembolism (on Coumadin) was admitted with shortness of breath and profound hypoxia. She had a retained fractured dialysis catheter from the superior to inferior vena cava. Imaging showed thrombotic bicaval occlusion, with extensive collateralization from peri‑hepatic and chest wall veins to the right pulmonary veins. Due to poor neurological status due to hypoxic brain injury and refractory hypoxemia, family opted to pursue comfort care. A comprehensive literature search yielded 29 additional cases of SPVSs, with a male majority (53 %) and mean age of 43.5 years. Only 7 cases (∼23 %) reported bicaval obstruction, all occurring during or after the year 2000. We highlight SPVSs as a possible cause of refractory hypoxia. Early intervention to relieve central obstruction and exclude SPVSs is the cornerstone of management.

Primary mediastinal T-ALL presenting with superior vena cava syndrome

Superior vena cava syndrome (SVCS) is a rare but serious condition typically associated with malignancy. While lung cancer and lymphoma are common causes, less frequent aetiologies can present a diagnostic challenge. We report a case of a young adult female who presented with classical symptoms of SVCS, including facial oedema, neck vein distention and dyspnoea. Diagnostic workup revealed a large mediastinal mass, which was subsequently confirmed as T cell acute lymphoblastic leukaemia (T-ALL) on biopsy. This case highlights the importance of considering T-ALL in the differential diagnosis of SVCS, particularly in younger individuals without traditional risk factors. Early recognition and prompt initiation of appropriate therapy, including chemotherapy and potentially radiation therapy, are crucial for optimal patient outcomes. This case underscores the need for a high index of suspicion for rare malignancies, even in the context of common presentations.

Combined chylothorax and chylopericardium: a complication of central venous catheter-related thrombosis

Central venous catheter-related thrombosis can lead to the concurrent occurrence of chylothorax and chylopericardium. This article reports a case of end-stage kidney disease with long-term dialysis catheter use, resulting in central vein stenosis and the rare complication of combined chylothorax and chylopericardium.

Managing superior vena cava syndrome in patients with cardiac implantable electronic device leads: Strategies and considerations

BACKGROUND

Data on transvenous (TV) lead-associated superior vena cava (SVC) syndrome are limited. The management of this problem might require a multidisciplinary approach, often involving transvenous lead extraction (TLE) followed by angioplasty and stenting.

OBJECTIVE

The purpose of this study was to describe the management and outcome of TV lead-associated SVC syndrome.

METHODS

We retrospectively identified patients with a diagnosis of SVC syndrome and TV leads at Emory Healthcare between 2015 and 2023.

RESULTS

Fifteen patients with lead-related SVC syndrome were identified. The cohort average age was 50 years. Symptoms included swelling of the face, neck, and upper extremities (67%); shortness of breath (53%); and lightheadedness (40%). Patients had an average of 2 ± 0.7 leads crossing the SVC, with a lead dwell time of 9.8 ± 7.5 years. Thirteen patients were managed with TLE, followed by SVC stenting and angioplasty in 10 and angioplasty alone in 2; 1 patient had no intervention after TLE. One patient was managed with anticoagulation, and another had angioplasty and stenting with lead jailing. One patient experienced SVC perforation and cardiac tamponade during SVC stenting, which was managed successfully with a covered stent and pericardiocentesis. Among the 12 patients with TLE and angioplasty ± stenting, 7 underwent reimplantation of a transvenous lead. Two of those patients had symptoms recurrence, and none of the 5 patients without lead reimplantation had recurrence of symptoms.

CONCLUSION

Lead-related SVC syndrome management requires a multidisciplinary approach often including TLE followed by angioplasty and stenting. Avoiding TV lead reimplantation might help reduce symptoms recurrence.

Surgical technique and outcomes associated with the use of femoral vein in venous reconstruction for superior vena cava syndrome

OBJECTIVE

Superior vena cava syndrome (SVC) is a debilitating disease, and surgical reconstruction has been described with some of the best results using spiral great saphenous vein (SGSV) grafts. SGSV grafts can be difficult to construct, and a long segment of saphenous vein is needed. Femoral vein has been an excellent conduit for infected aortic and peripheral reconstructions in our hands, and we sought to review outcomes using this conduit for SVC reconstruction.

METHODS

This was a single-center, retrospective study that included all patients who underwent SVC reconstruction using femoral vein from January 2000 to December 2023. Follow-up period analysis included reconstruction patency, surgical reinterventions, patient's symptoms, and complications.

RESULTS

Ten patients underwent central venous reconstruction or bypass using the femoral vein, with an average age of 51.88 years ± 10.20 years. SVC syndrome was primarily caused by benign etiologies including pacemakers and indwelling central venous catheters. Common presenting symptoms included head or neck fullness and upper extremity edema. The median follow-up duration was 21 months. Primary patency at 1 year was 79%.

CONCLUSION

Femoral vein reconstruction presents a promising solution for managing SVC obstruction, offering effective symptom relief and acceptable venous patency rates. Further research including prospective trials and comparative studies is crucial to refining surgical techniques and understanding long-term efficacy in addressing this complex clinical issue.

Arteriovenous access creation for hemodialysis patients with superior vena cava occlusion

BACKGROUND

The feasibility of creating arteriovenous (AV) access in hemodialysis patients with superior vena cava occlusion (SVCO) is debated due to impaired blood return to the right atrium. However, collateral venous networks may offer an alternative solution, allowing for the creation of peripheral AV access. This study evaluates the outcomes of AV access construction in hemodialysis patients with SVCO.

METHODS

A retrospective review of 18 patients with SVCO and patent azygous veins was conducted between August 2021 and June 2023. These patients underwent peripheral AV access creation, including fistulas and grafts. Collected data included baseline demographics, preoperative 3D CT reconstruction of thoracic vessels, central venography, vascular access types, surgical details, postoperative complications, and the timing and methods of interventions.

RESULTS

AV access was successfully created in all patients, including 15 AV fistulas and 3 AV grafts. The average brachial blood flow rate before cannulation was 848.67 ± 132.03 mL/min. The median follow-up period was 18.5 months (range: 10-32 months). During follow-up, six patients required interventions, such as flow reduction or percutaneous transluminal angioplasty, to optimize blood flow or resolve venous obstruction. Two cases were classified as failed access at 10 and 18 months post-creation. One patient transitioned to peritoneal dialysis due to AVG dysfunction, while the other underwent bypass surgery for chylothorax.

CONCLUSION

AV access can be successfully created and maintained in patients with SVCO and a patent azygous vein. Although mild venous obstruction symptoms may develop during follow-up, timely intervention can preserve access patency. For patients with limited vascular resources and challenging catheterization, this approach represents a viable option for establishing effective access.

Pacemaker-Induced Superior Vena Cava Syndrome

Superior vena cava (SVC) syndrome is a result of impaired blood flow from the SVC to the right atrium, leading to venous congestion in the head and neck. It can be caused by clotting disorders or compressive tumors of the head and neck but has become more prevalent in the setting of implantable devices such as pacemakers. As such, managing these patients can present challenges for physicians who have to account for SVC syndrome as well as their underlying condition requiring an implantable cardiac device. Our case represents one such patient who developed SVC syndrome as a result of pacemaker lead-related formation that was treated with both invasive and noninvasive therapy. This presentation highlights the successful management of SVC syndrome in a patient with sick sinus syndrome. It also demonstrates the efficacy of balloon angioplasty in managing this particular type of SVC syndrome, as well as exemplifying the use of leadless pacemaker devices as a means of long-term prevention.

Inferior and Superior Vena Cava Reconstruction

Obstructions of the superior and inferior vena cava are prevalent etiologies of deep venous obstruction, presenting a spectrum of clinical manifestations ranging from life-threatening conditions to asymptomatic states. The etiological diversity inherent to these central venous obstructions necessitates a subtle approach to their diagnosis and management. This discrepancy in clinical presentations emphasizes the importance of a differentiated diagnostic and therapeutic strategy, tailored to the specific form of vena cava obstruction encountered. This article aims to delineate the various manifestations of vena cava obstruction and encourages specific diagnostic and treatment pathways.

Chylopericardium and Superior Vena Cava Syndrome Caused by Central Venous Occlusion From Indwelling Hemodialysis Catheters

Chylopericardium is a rare condition. Causes include superior vena cava syndrome resulting from indwelling catheters. We present a case of this condition in a 42-year-old man with end-stage renal disease treated with hemodialysis through a right subclavian vein catheter. He underwent successful endovascular stenting with resolution of his symptoms and chylopericardium.

End-stage renal disease in a critical patient with superior vena cava syndrome with central vein catheters inserted via the superficial femoral vein: A case study

Superior vena cava syndrome (SVCS) is caused by obstruction to the blood flow through this vein. Indwelling central venous devices, such as cardiac pacemakers and haemodialysis catheters have emerged as the most common benign aetiology of SVCS. SVCS is particularly severe in patients with end-stage renal disease who require continuous renal replacement therapy plus infusion therapy. The presence of SVCS results in a reduction of available venous access for affected patients. Therefore, venous access plays a crucial role in the management of these patients. The importance of dealing with vascular access (VA) in critical patients with these conditions cannot be overstated. This case describes an 81-year-old man with respiratory failure who had end-stage renal disease complicated with SVCS. Using ultrasound-guided puncture, we inserted a peripherally inserted central catheter (PICC) into the superficial femoral vein to meet his infusion requirements in intensive care. After successful placement, the catheter tip position was adjusted using imaging to position the tip relative to the haemodialysis catheter. Whenever patients with severe renal dysfunction are treated, central veins should be preserved. Safe PICC access is possible via the superficial femoral vein to protect the last central VA for rational use. This meets urgent needs for infusion and deserves promotion.

Newly Designed, Self-Expanding Large-Bore Nitinol Stents for Symptomatic Central Venous Stenosis: Technical and Long-Term Clinical Outcome

PURPOSE

To retrospectively analyze the technical and long-term clinical outcome of angioplasty and stenting using the Venovo™ venous stent for the treatment of malignant and benign superior vena cava (SVC) occlusive disease.

MATERIALS AND METHODS

Consecutive patients treated with the Venovo™ venous stent for SVC occlusive disease were included. SVC obstruction symptoms were classified according to the Kishi score. The Wilcoxon signed-rank test was used for testing significance of changes. Technical success, defined as correct placement of the stent, completely covering and re-expanding the obstruction, between groups was tested using the Fisher exact test. Overall survival was calculated using the Kaplan-Meier method.

RESULTS

Fifty-five patients underwent stent insertion for symptomatic benign (n = 13; 24%) or malignant (n = 42; 76%) SVC occlusive disease. A significant drop in Kishi score, mean 3.91 before versus mean 1.02 after the procedure (P < 0.0001), was observed. In one patient (1.8%), an additional balloon-expandable stent was needed to manage incomplete expansion of the nitinol stent. In one patient, a procedure-related lung embolic complication was noted. Early thrombotic occlusion of the stent occurred in one patient. Late symptomatic restenosis occurred in 3 patients. Overall primary stent patency and primary-assisted stent patency were 86% (95% CI 66-95) and 97% (95% CI 83-100) at 1-year follow-up and 98% (95% CI 87-100), 98% (87-100) at 2-year follow-up, respectively.

CONCLUSION

In this retrospective analysis, angioplasty and stent placement using the Venovo™ venous stent is safe and clinically effective for the treatment of both benign and malignant SVC occlusive disease. Reintervention for symptomatic restenosis is rare.

Safety and Effectiveness of Abre Self-Expanding Venous Stent for Treatment of Superior Vena Cava Syndrome

PURPOSE

Superior vena cava (SVC) syndrome is a constellation of symptoms that results from partial or complete SVC obstruction. Endovascular SVC stenting is an effective treatment for SVC syndrome with rapid clinical efficacy and low risk of complications. In this study, we assess the technical and clinical outcomes of a cohort of patients with SVC syndrome treated with the AbreTM self-expanding venous stent (Medtronic, Inc, Minneapolis, MN, USA).

METHODS

An institutional database was used to retrospectively identify patients with SVC syndrome treated with AbreTM venous self-expanding stent placement between 2021-2023. Patient demographic data, technical outcomes, treatment effectiveness, and adverse events were obtained from the electronic medical record. Nineteen patients (mean age 58.6) were included in the study. Thirteen interventions were performed for malignant compression of the SVC, 5 for central venous catheter-related SVC stenosis, and 1 for HD fistula-related SVC stenosis refractory to angioplasty.

RESULTS

Primary patency was achieved in 93% of patients (17/19). Two patients (7%) required re-intervention with thrombolysis and angioplasty within 30 days post-stenting. Mean duration of clinical and imaging follow-up were 228.7 ± 52.7 and 258.7 ± 62.1 days, respectively. All patients with clinical follow-up experienced significant improvement in clinical symptoms post-intervention. No stent related complications were identified post-intervention.

CONCLUSIONS

Treatment of SVC syndrome with the AbreTM self-expanding venous stent has high rates of technical and clinical success. No complications related to stent placement were identified in this study.

Superior Vena Cava Syndrome Masquerading as Angioedema: A Chemotherapy Port Complication

Superior vena cava (SVC) syndrome is a constellation of symptoms that occur secondary to external compression of the SVC, most commonly by a mediastinal malignancy. With the increased use of implanted cardiac devices and indwelling central venous catheters, SVC syndrome from a benign cause has become quite common. This report follows a 62-year-old female who was initially admitted to the critical care unit for treatment of angioedema without a history of malignancy but was found to have a surgically placed port used to treat her rheumatoid arthritis. Despite treatment of what was presumed to be angioedema, her symptoms failed to resolve. Imaging of the thorax revealed a venous thrombosis in the previously placed port. The port was subsequently removed, and the patient's symptoms hastily resolved. This case report underscores the importance of obtaining a thorough history, maintaining a broad differential diagnosis, and revising the differential when the patient's symptoms fail to improve.

Essential Review of Oncological Emergencies

Innovations in oncology have expanded treatment eligibility, leading to a rise in cancer patients requiring critical care. This necessitates that all critical care clinicians possess a fundamental knowledge of prevalent oncological conditions and identify emergent scenarios requiring immediate action. This article will explore key oncological complications and their management approaches.

Brachiocephalic Vein Reconstruction Following the Excision of a Large Suspicious Anterior Mediastinal Mass

Superior vena cava syndrome (SVCS) is a clinical condition characterized by signs and symptoms resulting from the blockage or narrowing of the thin-walled superior vena cava (SVC). This obstruction can lead to significant morbidity and mortality. In this case, we report a 58-year-old patient who was diagnosed with SVCS due to a massive compressing anterior mediastinal mass leading to signs and symptoms of SVCS, including shortness of breath, dizziness, palpitations, and neck swelling, which was managed surgically by excision of the mass and reconstruction of the brachiocephalic vein using a synthetic graft.

Syncope Due to Iatrogenic Cava Vein Obstruction: Rare Complication of Cardiac Implantable Electronic Device Leads

A 77-year-old female patient with multiple pacemaker leads experienced hypotension and syncope during right heart catheterization. Imaging studies revealed a stenotic inferior vena cava with superior vena cava obstruction and well-developed retrograde collateral vessels, suggesting that balloon obstruction of the sole venous return site caused low cardiac output leading to syncope.

Unveiling the culprit: Exploring malignant thrombotic superior vena cava obstruction

This case image describes the complex proposed etiologies of a case of superior vena cava syndrome. Hence, different diagnostic and therapeutic modalities are needed in a multidisciplinary team approach.

Percutaneous Image-Guided Treatment of Pediatric Deep-Vein Occlusions

Pediatric venous occlusions are a growing cause of morbidity and mortality, especially in hospitalized patients. Catheter-directed recanalization is a safe and effective treatment option in appropriately selected patients. Benefits of catheter directed therapies (CDTs) include the prevention of pulmonary embolism and end organ failure acutely as well as superior vena cava syndrome and post-thrombotic syndrome chronically. Timely diagnosis, recognition of underlying factors for thrombosis, and familiarity with the spectrum of tools and techniques for CDT are essential to optimizing outcomes in the acute setting. Recanalization of chronic venous occlusions can similarly provide symptomatic relief and achieve long term vessel patency. This review will detail the scope, techniques, and outcomes for CDT in the treatment of acquired systemic deep vein occlusions.

Appropriate Use Criteria Committees: The professional society role in the development and implementation of Appropriate Use Criteria

Vascular surgeons have the ability to manage and intervene on numerous vascular diseases of both the arterial and venous systems. With the growing number of interventions available as endovascular technology evolves, it is important to determine when a procedure is safely indicated for a vascular surgery patient. Appropriate Use Criteria (AUC) offer synthesized clinical information and practice standards that can aid clinicians in making these management decisions. Professional societies, such as the Society for Vascular Surgery, bring experts in the field together to collaborate and create AUC for various vascular diseases and interventions. It is essential to publish these criteria in peer-reviewed journals, as well as make them available on public websites so the information is available to vascular surgeons and interventionalists from other specialties who also treat patients with vascular disease. Cardiology, interventional radiology, and interventional nephrology are some other specialties that perform procedures for vascular disease, and vascular interventions by nonsurgeon specialists continue to increase. The Society for Vascular Surgery has published AUC on intermittent claudication, carotid disease, and abdominal aneurysm management. These are intended to guide practice, but also have highlighted areas for improvement that would allow for more universal implementation of AUC in vascular patient care across medical specialties. Increased intersocietal participation and perhaps inclusion of government and other payer participation will allow professional society-sponsored AUC to evolve, resulting in coordinated, appropriate care for vascular surgery patients.

[Translation into French and republication of: "Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management"]

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy.

A Superior Squeeze: Superior Vena Cava Syndrome Secondary to Small Cell Lung Cancer

Superior vena cava (SVC) syndrome is an uncommon yet potentially fatal syndrome occurring after intrinsic or extrinsic compression to the SVC. While there are multiple emerging etiologies for this phenomenon, malignancy remains the most common. It is characterized by several symptoms including facial swelling, extremity swelling, shortness of breath, and headaches. We present the case of a 59-year-old female with a past medical history of cocaine abuse who was admitted for upper extremity swelling and facial edema. Imaging revealed a right suprahilar mass compressing a branch of the right pulmonary artery and SVC, in addition to bilateral segmental and subsegmental pulmonary emboli. She underwent an emergent biopsy and SVC stenting, with immunostaining revealing small cell lung cancer (SCLC). This case highlights a severe presentation of SVC syndrome caused by previously undetected SCLC.

Unveiling a Unique Presentation of Superior Vena Cava Syndrome Succeeding a Traumatic Motor Vehicle Crash and Implantable Cardioverter-Defibrillator Lead Placement

Superior vena cava (SVC) syndrome, once a rarity, has seen an uptick in cases with diverse origins. While this disease process is clinically diagnosable, imaging modalities and tissue biopsies further refine interventions. The clinical presentation includes but is not limited to edema of the arms, neck, and head, facial plethora, cyanosis, and or distention of subcutaneous vessels. SVC syndrome can be attributed to extrinsic compression or thrombosis in many cases. If symptoms are not life-threatening, the overall morbidity is based on the underlying root cause. Few cases have been reported with associated death due to epistaxis. However, the obstruction itself can be initially asymptomatic and then slowly progress over months to years. This case report highlights a distinct instance of SVC syndrome with notable risk factors: implantable cardioverter defibrillator placement and prior cardiac trauma status post-intervention.

Uncommon Presentation of Recurrent Lung Adenocarcinoma: A Finger Ulcer Induced by Subclavian Artery Invasion Successfully Healed With Viabahn VBX Treatment

Recurrence of a lung tumor invading the subclavian artery, causing stenosis and leading to finger ulcers as the initial symptom, is rare. We employed endovascular techniques, inserting a Viabahn® VBX covered stent (W. L. Gore & Associates, Flagstaff, Arizona) to aid in ulcer healing and improve the patient's quality of life. The patient, a 73-year-old male, had a history of lung adenocarcinoma resection two years prior but had not undergone follow-up examinations or cancer-specific treatments. Clinical examination revealed an invasion of the right subclavian artery by the recurrent tumor, resulting in severe stenosis and ischemic symptoms in the right upper limb. Given the patient's advanced cancer stage and the decline of further tumor-specific treatments, an endovascular intervention using a Viabahn VBX covered stent was performed to improve blood flow and promote ulcer healing. The stent demonstrated exceptional stability and patency during the six-month follow-up, greatly improving the patient's quality of life. This case highlights the importance of recognizing atypical symptoms as potential indicators of tumor recurrence or progression and demonstrates the promising role of covered stents in managing vascular complications in selected patients with advanced-stage malignancies.

Surgical resection of an intraluminal tumor in the azygos vein with an unknown primary site causing superior vena cava syndrome

Intraluminal tumor in the azygos vein is a rare disease that can cause superior vena cava (SVC) syndrome. Radiotherapy and endovascular stenting with or without chemotherapy are reported to have a high clinical success rate for the management of SVC syndrome with malignancy, but a poor survival rate. Here, we report a 69-year-old man who presented with swelling of the face and upper extremities, who was diagnosed with SVC syndrome caused by an intraluminal tumor in the azygos vein. Enhanced chest computed tomography revealed an intraluminal mass with a filling defect from the azygos vein to the SVC, with no extravascular extension or dissemination of the primary tumor. Surgical resection of the mass en bloc with the azygos vein and SVC reconstruction was performed. A poorly differentiated carcinoma was diagnosed on postoperative pathological evaluation. Twelve months after resection, the patient was well with no signs of recurrent disease. This case highlights that surgical resection should be considered as a treatment of choice for the management of SVC syndrome caused by an intraluminal malignancy in the azygos vein.

Superior vena cava syndrome in chronic intestinal failure patients: When the going gets tough

BACKGROUND & AIMS

Catheter-related venous thrombosis is a severe complication of home parenteral nutrition (HPN) with potentially devastating consequences such as superior vena cava syndrome (SVCS). Early recognition and awareness of factors leading to its development are of paramount importance. However, studies are lacking in HPN patients focusing on this topic. In this study, we aimed to determine the incidence of SVCS in HPN patients and describe SVCS-related outcomes.

METHODS

This retrospective cohort study comprised all adult HPN patients who developed SVCS between 2000 and 2022 at our national HPN referral center. Primary outcome was the incidence of SVCS. Secondary outcomes include SVCS-related symptoms, tip location of central venous access device (CVAD) post-insertion and at time of SVCS, diagnostics and treatment.

RESULTS

SVCS was diagnosed in 38 of 616 patients (6%), with an annual cumulative incidence rate ranging between 0 and 4.2%. Most common presenting symptoms were facial edema (82%) and arm edema (50%). Post-insertion, 17% (6/36) of patients had a correct position of the CVAD tip and 11% (4/36) during SVCS diagnosis. Computed tomography was the most used diagnostic imaging technique (66%). Sixty-three percent of patients started, 11% switched, and 21% continued anticoagulant treatment.

CONCLUSIONS

The incidence of SVCS is relatively high in our vulnerable HPN population. It is key to recognize whenever such patients present with vascular obstruction-related symptoms and treat them in an early stage by a multidisciplinary team.

Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least three months, including at least one month after catheter removal following initiation of therapy.

"Complete Venous Shutdown:" A Rare Case of Combined Superior Vena Cava (SVC) and Inferior Vena Cava (IVC) Occlusion

Independently, superior vena cava (SVC) occlusion and inferior vena cava (IVC) occlusion are usually seen in the setting of SVC syndrome and iliocaval venous obstruction (ICVO), respectively. Concomitant occlusion of the SVC and IVC is rare and most commonly seen in the setting of malignancy or other hypercoagulable states. Venous hypertension can lead to the formation of "downhill" varices in the esophagus and can be a rare source of gastrointestinal bleeding. We present a rare case of combined SVC and IVC occlusion and its management.

Superior vena cava syndrome induced by lung hyperinflation in chronic obstructive pulmonary disease: a case report

BACKGROUND

Superior vena cava syndrome is rarely attributed to chronic obstructive pulmonary disease.

CASE PRESENTATION

We present the case of an 82-year-old Japanese man who experienced gradually progressive dyspnea on exertion. His physical examination revealed small vascular dilatations on his chest and upper abdominal skin characterized by blood flow from head to leg, indicating superior vena cava syndrome. Radiographic findings included lung hyperinflation with a drop-like heart on chest X-ray, and emphysematous changes on computed tomography. The superior vena cava appeared extremely narrow and slit-like, with no adjacent mass or giant bulla. Pulmonary function testing indicated a forced expiratory volume in 1 second of 0.82L (44.4% of predicted value) and a forced expiratory volume in 1 second/forced vital capacity of 31.29%. A diagnosis of chronic obstructive pulmonary disease was made. We discuss how longitudinal forces can narrow the superior vena cava, particularly when it protrudes toward the lung field due to its anatomical location in the upper mediastinum. The absence of mediastinal adipose tissue may render the superior vena cava susceptible to compression, resulting in a loss of its typical columnar structure. The protrusion of the superior vena cava toward the lung field may be a contributing factor to superior vena cava narrowing in chronic obstructive pulmonary disease.

CONCLUSION

This case represents the first reported instance of superior vena cava syndrome associated with chronic obstructive pulmonary disease, characterized by lung hyperinflation, in the absence of a giant bulla.

Predictive Factors for Infusion Site Induration After Outpatient Chemotherapy in Japan: A Secondary Analysis

PURPOSE

Even in the absence of extravasation, some patients develop induration at the peripheral intravenous catheterization site prior to the next day's treatment. Infusion site induration commonly affects patients who undergo repeated chemotherapy administrations. Vessel health is crucial for the continuation of chemotherapy. However, there is no effective method to prevent induration. Hence, this study aimed to investigate the factors that could cause induration for preventing its occurrence.

METHODS

This study was a secondary analysis of a prospective observational study. All participants were undergoing outpatient chemotherapy. Participant characteristics and related catheterization data were collected on the treatment day as baseline, and induration incidence was recorded on the subsequent treatment day. Receiver operating characteristic (ROC) analysis was performed to determine the sensitivity and specificity of cutoff points of the vein and catheter diameter ratios for distinguishing between developed induration and not developed induration. Additionally, cox regression analysis with multiple imputation was used to investigate the factors that predicted induration.

RESULTS

Seventy-one patients participated in the study. The cutoff point of the vein/catheter diameter ratio calculated using ROC analysis was ≥3.7. The ratio of larger-diameter veins to catheter diameter of ≥3.7 times was negatively associated with induration in both complete case analysis (HR: 0.11; p = 0.034) and multiple imputation analysis (HR: 0.12; p = .049).

CONCLUSIONS

Selecting the vein with 3.7 times higher diameter than the catheter diameter for the catheterization site may help prevent induration on the next treatment day.

Management with right atrium to jugular and brachiocephalic vein bypass for dialysis catheter-related superior vena cava syndrome

Superior vena cava (SVC) syndrome is a spectrum of potentially life-threatening clinical manifestations resulting from either partial or complete obstruction of central venous blood flow. Approximately 70% of cases are caused by malignancy. The primary treatment end point for SVC syndrome is the achievement of long-term patency of the SVC. Malignant SVC syndrome is managed by either radiation therapy, open surgical intervention, or endovascular therapy with angioplasty and stenting. The current report describes an uncommon case of nonmalignant SVC syndrome resulting from complications of hemodialysis catheters that was managed with open revascularization between the right internal jugular and brachiocephalic veins and the right atrium.

A Case of a Constricted Vessel: The Impact of Acute Myeloid Leukemia on the Superior Vena Cava

Acute myeloid leukemia (AML) is the most prevalent form of leukemia in adults, with rising global incidence rates. AML usually presents with non-specific clinical features such as pallor, fever, and bleeding. This case report discusses a unique presentation of AML, where a 25-year-old female with a history of hypertension presented with unilateral facial swelling, chest pain, and shortness of breath. Radiologic investigations revealed a mediastinal mass encasing the superior vena cava (SVC), confirming the suspicion of SVC syndrome. Upon testing with a biopsy, the mass was found to be composed of immature myeloid cells confirming the diagnosis of myeloid sarcoma-associated AML. The patient's treatment involved a combination of surgical debridement, induction chemotherapy, supportive care, and management of complications. This case highlights that despite its common occurrence, AML may present with atypical clinical manifestations such as SVC syndrome, posing challenges in its diagnosis and timely management.

Germ Cell Tumor Complicated by Mediastinal Mass Syndrome: A Report of Cardiac Arrest to Full Recovery

Germ cell tumors (GCTs) are the most common malignancies in men aged 15-35 years. Five percent of malignant GCTs are of extragonadal origin, and the most common extragonadal location for GCTs in adults is the mediastinum. Like other mediastinal tumors, mediastinal GCTs may cause compression or invasion of vital mediastinal structures, resulting in respiratory or hemodynamic compromise. Right ventricular failure following positive pressure ventilation of such patients is called mediastinal mass syndrome (MMS). This report presents a case of a GCT complicated by cardiac arrest shortly after starting positive pressure ventilation, which was successfully resuscitated. Few previous reports demonstrated a successful outcome of MMS. This report highlights the importance of a multidisciplinary approach for such scenarios in light of the scanty literature and lack of clear guidance and the significance of starting chemotherapy in a timely manner.

Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.

Superior Vena Cava Syndrome: An Umbrella Review

Superior vena cava syndrome (SVCS) is a medical emergency that encompasses an array of signs and symptoms due to obstruction of blood flow through the superior vena cava (SVC). It poses a significant healthcare burden due to its associated morbidity and mortality. Its impact on the healthcare system continues to grow due to the increasing incidence of the condition. This incidence trend has been attributed to the growing use of catheters, pacemakers, and defibrillators, although it is a rare complication of these devices. The most common cause of SVCS remains malignancies accounting for up to 60% of the cases. Understanding the pathophysiology of SVCS requires understanding the anatomy, the SVC drains blood from the right and left brachiocephalic veins, which drain the head and the upper extremities accounting for about one-third of the venous blood to the heart. The most common presenting symptoms of SVCS are swelling of the face and hand, chest pain, respiratory symptoms (dyspnea, stridor, cough, hoarseness, and dysphagia), and neurologic manifestations (headaches, confusion, or visual/auditory disturbances). Symptoms generally worsen in a supine position. Diagnosis typically requires imaging, and SVCS can be graded based on classification schemas depending on the severity of symptoms and the location, understanding, and degree of obstruction. Over the past decades, the management modalities of SVCS have evolved to meet the increasing burden of the condition. Here, we present an umbrella review providing an overall assessment of the available information on SVCS, including the various management options, their indications, and a comparison of the advantages and disadvantages of these modalities.