Superior Vena Cava Syndrome in Emergency Medicine Treatment & Management

Updated: Sep 19, 2016
  • Author: Michael S Beeson, MD, MBA, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Treatment

Prehospital Care

Prehospital caregivers are aware of the superior vena cava syndrome (SVCS) diagnosis only on occasion.

The usual attention to airway, breathing, and circulation (ABCs) is required.

Superior vena cava syndrome only rarely manifests as a life-threatening entity; therefore, other causes for the symptomatology must be sought.

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Emergency Department Care

Superior vena cava syndrome only rarely manifests as an acute emergency. Typically, the syndrome develops over weeks to months and is recognized when the typical signs of facial and upper extremity edema occur. Confusion related to associated cerebral edema or stridor from laryngeal edema and impending airway obstruction represent acute emergencies.

Attention to the ABCs is essential.

If patients are allowed to sit upright, they may experience some relief of the usual dyspnea.

Stabilize the airway, as needed, and consider steroids.

If cerebral/airway edema is present, consider diuretics; however, diuretics have not shown consistent benefit in the emergency department (ED).

Endovascular shunts are increasingly used, as are thrombolytics if a thrombotic cause is present.

Cui and colleagues reported on the development of acute superior vena cava (SVC) syndrome in a 28-year-old woman with end-stage renal disease who was implanted with a left-side hemodialysis reliable outflow graft and a right-side double lumen hemodialysis catheter via internal jugular veins. The patient’s symptoms were not alleviated after catheter removal and systemic anticoagulation therapy. Eventually, she was successfully treated with catheter-directed thrombolysis, demonstrating that this method can be safely used to treat refractory catheter-induced acute SVC syndrome in end-stage renal disease patients. [5]

After a tissue diagnosis, radiation and chemotherapy may be initiated.

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Consultations

Over the last 10 years, considerable experience with endovascular stenting of superior vena cava syndrome has been achieved. [6, 7] At many centers, endoprostheses have become the initial choice for palliative treatment of superior vena cava syndrome.

In a retrospective study that evaluated the self-expanding nitinol Sinus-XL stent for the treatment of superior vena cava (SVC) obstruction caused by non-small cell lung cancer (NSCLC), investigators studied 23 patients with NSCLC and acute SVC obstruction who were scheduled for urgent stent implantation. The primary study endpoints were technical success, residual stenosis < 30%, and clinical efficacy. Results provided evidence that in this palliative setting, implantation of the self-expanding Sinus-XL stent for treatment of SVC obstruction caused by NSCLC is a safe and effective urgent treatment. [8]

Emergent consultation with radiation therapy may be necessary, depending upon the acuteness of the presentation.

Because most causes of superior vena cava syndrome are related to lung cancer, a pulmonary or oncology consultation may be obtained.

Generally, considering the diagnosis in the ED is important. If the diagnosis is made de novo in the ED, only rarely is emergent consultation necessary. Exceptions include sudden airway compromise or acute superior vena cava thrombosis, which may occur from an indwelling catheter.

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