Superior Vena Cava Obstruction: A Rare Cause of Recurrent Esophageal Variceal Bleeding

"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.

Downhill esophageal varices: a systematic review of the case reports

Aim: The etiologies, presentation, and management of downhill varices in the era of modern medicine are relatively under-explored and mostly limited to case reports or case series. Methods: Published case reports/series of patients ≥ 18 years old with proven/probable downhill esophageal varices were searched on Ovid MEDLINE and Ovid EMBASE for all published cases up to January 2021. Results: The mean age was 50.9 (standard deviation ± 17.6) years old for all downhill variceal cases. End-stage renal disease was the most common comorbidity (43.9%), followed by thyroid disease (12.2%), Behçet’s disease (9.8%), and pulmonary hypertension (7.3%). Dialysis catheters, central venous grafts, or additional catheters were additional risk factors (51.2%). Variceal bleeding presenting as hematemesis, melena, or both was the most common presenting symptom (80.5%). Conclusions: Dialysis catheter-associated superior vena cava obstruction resulted in an increased risk of downhill varices. Other causes include thyroid malignancies, pulmonary hypertension, and Behçet’s disease.

Hematemesis, a Rare Presentation for Downhill Esophageal Varices

Downhill esophageal varices (DEV) are a rare form of esophageal varices associated with superior vena cava obstruction. Obstruction leads to retrograde blood flow through collateral venous channels, including the esophageal venous plexus, to redirect blood flow to the right atrium via the inferior vena cava. This leads to the formation of DEV. It is a rare phenomenon to have gastrointestinal bleeding, especially hematemesis, on a patient's first presentation with this disease process. We describe such a case here involving a patient with DEV secondary to metastatic renal cell carcinoma presenting with hematemesis.