Chest

Chest

Volume 103, Issue 4, Supplement, April 1993, Pages 394S-397S
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Article
Approach to the Patient Who Presents With Superior Vena Cava Obstruction

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Clinical suspicion of SVC syndrome should prompt urgent attention, but in the absence of tracheal obstruction, the symptoms of SVC occlusion are unlikely to prove life threatening. It is therefore possible to consider both the immediate and long-term goals of therapy for the patient with SVC syndrome.

Diagnostic procedures of proven value include chest x-rays, chest CT, and nuclear flow studies. A tissue diagnosis should be obtained if possible; noninvasive measures such as sputum cytology have a high success rate. General anesthesia, if required, is usually possible with a low incidence of complications.

Treatment of SVC syndrome should be individualized. Small-cell lung cancer and lymphomas respond well to multiagent chemotherapy. Radiotherapy leads to symptomatic improvement in the majority of patients, although long-term survival for those with bronchogenic carcinoma is poor. Patients with indwelling central lines or cardiac pacemakers are at risk of thrombus formation and may require anticoagulation therapy. Surgical reconstruction may be of value in carefully selected patients.

Section snippets

Pathophysiology and Presentation

The superior vena cava (SVC) is formed by the union of the right and left brachiocephalic veins and empties into the superior-posterior right atrium. It is the major drainage system for blood returning from the upper extremities and head and neck. The azygos vein is the only major vein that enters the SVC and carries blood returned from the posterior torso. The SVC is relatively thin-walled and lies within a nondistensible space in the mediastinum, making it susceptible to extrinsic compression

Radiologic Studies

In a patient who presents with clinical evidence of SVC obstruction, the radiologic workup establishes the diagnosis, guides attempts at pathologic confirmation, and aids in management decisions. Routine studies of demonstrated use include chest x-rays, CT and magnetic resonance imaging (MRI) scans, venography, and nuclear flow studies. Limited trials have reported the use of Doppler flow studies,10 echocardiography,11 and digital subtraction angiography.12

A chest x-ray will prove useful in

Biopsy Procedures

Controversy often arises in the management of a patient with SVC obstruction as to the need for pathologic confirmation of malignancy prior to initiating therapy. In most cases, this is both desirable and possible. Treatment without an established diagnosis should be initiated only in those patients with rapidly progressive symptoms or those in whom multiple attempts to obtain a tissue diagnosis have been unsuccessful. The physician must keep in mind that the ultimate treatment strategy will

Management

Patients with clinical SVC syndrome often gain significant symptomatic improvement from conservative treatment measures, including elevation of the head of the bed and supplemental oxygen. Corticosteroids and diuretics are often used, although documentation of their efficacy is lacking. These maneuvers usually allow time to evaluate the pathology specimen prior to initiating therapy.

As noted above, bronchogenic carcinomas are the most common cause of SVC syndrome today. Small-cell lung cancer

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    Copyright © 1993 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.