Superior Vena Cava Syndrome Workup

  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Aug 13, 2010
 

Imaging Studies

  • Patients presenting with overt superior vena cava syndrome (SVCS) may be diagnosed by means of physical examination alone. However, subtle presentations require diagnostic imaging. Chest radiography may reveal a widened mediastinum or a mass in the right side of the chest. Only 16% of the patients studied by Parish and colleagues in 1981 had normal findings on chest radiography.[19]
  • CT has the advantage of providing more accurate information on the location of the obstruction and may guide attempts at biopsy by mediastinoscopy, bronchoscopy, or percutaneous fine-needle aspiration.[7] It also provides information on other critical structures such as the bronchi and the vocal cords. See the image below.
    • A CT scan of the chest is the initial test of choice to determine whether an
    • obstruction is due to external compression or due to thrombosis.
    • The additional information is necessary because the involvement of these structures requires prompt action for relief of pressure.Superior vena cava syndrome (case 1). The patient Superior vena cava syndrome (case 1). The patient was a 35-year-old man with a 3-year history of progressive upper-extremity and fascial swelling. The patient had undergone treatment for histoplasmosis in the past. CT scan shows a narrowed superior vena cava with adjacent calcified lymph nodes and posterior soft tissue thickening.
  • MRI has not been sufficiently investigated, but it appears promising.
    • It has several potential advantages over CT scanning, including the fact that it provides images in several planes of view and allows direct visualization of blood flow. Furthermore, MRI does not require iodinated contrast material. This is especially important when stenting is anticipated.[20]
    • MRI is an acceptable alternative for patients with renal failure or those with contrast allergies.
    • Disadvantages may include increased scanning time with attendant problems in patient compliance and increased cost.
  • Invasive contrast venography is the most conclusive diagnostic tool.
    • It precisely defines the etiology of obstruction.
    • It is especially important if surgical management is being considered for the obstructed vena cava.Superior vena cava syndrome (case 1, cont'd). VenoSuperior vena cava syndrome (case 1, cont'd). Venogram shows almost complete occlusion of the superior vena cava with dramatic collateral drainage through the left superior intercostal vein.
  • Radionuclide technetium-99m venography is an alternative minimally invasive method of imaging the venous system. Although images obtained by this method are not as well defined as those achieved with contrast venography, they demonstrate potency and flow patterns.[22]
  • Gallium single-proton emission CT scanning may be of value in select cases.
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Procedures

  • Most patients with superior vena cava syndrome (SVCS) present before the primary diagnosis is established.
  • Controversy often arises in the treatment of a patient with superior vena cava syndrome (SVCS) in regard to the need for pathologic confirmation of malignancy before the start of therapy.
  • Treatment without an established diagnosis should be initiated only in patients with rapidly progressive symptoms or those in whom multiple attempts to obtain a tissue diagnosis have been unsuccessful.
  • Fortunately, relatively noninvasive measures establish the diagnosis in a high percentage of patients with superior vena cava syndrome (SVCS).
    • Sputum cytologic results are diagnostic in 68% of the cases, whereas biopsy of a palpable supraclavicular node is positive in 87%.[23]
    • Bronchoscopy has a 60% success rate, while thoracotomy is 100% successful.[23]
    • Open biopsy is rarely needed for diagnosis. Dosios et al showed that cervical mediastinoscopy and anterior mediastinoscopy are effective in establishing a histiologic diagnosis.[24]
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Contributor Information and Disclosures
Author

Todd A Nickloes, DO, FACOS  Assistant Professor, Department of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center-Knoxville

Todd A Nickloes, DO, FACOS is a member of the following medical societies: American College of Osteopathic Surgeons, American Medical Association, American Osteopathic Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

LaMar O Mack, MD  Resident Physician, Department of Surgery, University of Tennessee Medical Center

LaMar O Mack, MD is a member of the following medical societies: American Urological Association, National Medical Association, and Student National Medical Association

Disclosure: Nothing to disclose.

Andre M Kallab, MD  Clinical Associate Professor of Oncology, Medical College of Georgia; Consulting Staff, Department of Oncology, Northeast Georgia Diagnostic Clinic

Andre M Kallab, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Hematology

Disclosure: Nothing to disclose.

Allan Bernard Dunlap, MD  Fellow in Trauma/Surgical Critical Care, University of Tennessee Health Science Center College of Medicine

Allan Bernard Dunlap, MD is a member of the following medical societies: American College of Surgeons and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard M Stillman†, MD, FACS  Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center

Richard M Stillman†, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

References

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Superior vena cava syndrome (case 1). The patient was a 35-year-old man with a 3-year history of progressive upper-extremity and fascial swelling. The patient had undergone treatment for histoplasmosis in the past. CT scan shows a narrowed superior vena cava with adjacent calcified lymph nodes and posterior soft tissue thickening.
Superior vena cava syndrome (case 1, cont'd). Sonogram shows markedly damped venous waveform with complete loss of normal venous pulsatility and minimal respiratory variation.
Superior vena cava syndrome (case 1, cont'd). Venogram shows almost complete occlusion of the superior vena cava with dramatic collateral drainage through the left superior intercostal vein.
Superior vena cava syndrome (case 1, cont'd). A Palmaz P308 stent mounted on a 12-mm balloon was deployed in the superior vena cava after it was predilated to 8 mm. The stent was subsequently dilated to 14 mm.
Superior vena cava syndrome (case 1, cont'd). Venogram obtained after stenting shows a widely patent superior vena cava with no collateral drainage. Pressure measurements after stenting showed a 1- to 2-mm residual gradient.
Superior vena cava syndrome (case 1, cont'd). Sonogram obtained 1 year after stenting shows near-normal venous pulsatility and respiratory phasicity. The patient experienced a complete resolution of symptoms.
 
 
 
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