IS Case 315: SVC syndrome with stent placement

Charles Hubeny, MD

Imaging Sciences URMC 2009
Publication Date: 2009-09-14

History

Patient is an 83-year-old female with non-small cell lung carcinoma presenting with facial and left upper extremity swelling.

Findings

Findings compatible with superior vena cava (SVC) syndrome.

Diagnosis

SVC syndrome with stent placement

Discussion

Superior vena cava (SVC) syndrome results from obstruction of the vessel from either extrinsic mass effect, direct vessel invasion, and/or thrombus. The most common cause is from malignancy especially bronchogenic carcinoma and less commonly from lymphoma. Other causes include thrombosis from catheters or pacemaker leads. Infectious causes such as syphilis, TB, and fungi are much less common since the use of antibiotics. Partial obstruction is usually caused by extrinsic compression from neoplasm or adjacent adenopathy. Complete obstruction results from thrombus secondary to near complete extrinsic compression or direct invasion from malignancy.

Symptoms include dyspnea, headache, facial plethora, venous distension in the neck, upper chest, and arms, upper limb edema, and cough. Collateral veins enlarge to help the venous return when the SVC is obstructed. Pathways include the azygous system, the internal mammary system which leads to the superior and inferior epigastric veins, and other pathways including the long thoracic venous system, femoral veins, and vertebral veins.

Obstruction of the SVC is usually verified with contrast imaging such as from CT angiography, conventional angiography, or MRI. Ultrasound can be used but is not routinely. Treatment options include external beam radiation, chemotherapy, anti-coagulation, surgery (bypass, transposition), medical therapy (steroids, diuretics), or endovascular intervention such as catheter-directed thrombolysis followed by stent placement.

Endovascular management is palliative and is usually used in conjunction with other therapies. Advantages of stenting include immediate relief of symptoms whereas radiation or chemotherapy may take days to weeks to be effective. Complications are rare and include stent thrombosis or even migration especially after the tumor decreases in size from radiation or chemotherapy.

References

  1. Courtheoux P, Alkofer B, Al Refaï M, Gervais R, Le Rochais JP, Icard P. Stent placement in superior vena cava syndrome. Ann Thorac Surg. 2003 Jan;75(1):158-61. PMID: 12537210

5 images