SVC Obstruction

Summary
Obstruction of the superior vena cava usually results from local invasion by a malignant process.
Unless the airway is compromised, time should be taken to develop a treatment plan for the
underlying pathology, which may in itself be effective, though venoplasty may be necessary in
extremis.

Aetiology and Epidemiology

- Causes
• Malignant → see table
• Non-malignant thrombotic disorders (Behçet’s disease, nephrotic syndromes1), central line
thrombosis, ovarian hyperstimulation, lung fibrosis (e.g. post-chemotherapy)

Pathogenesis

Malignant causes of SVC obstruction

Malignancy%Non-small cell lung

cancer50Small cell lung
cancer22Lymphoma12Metastatic
carcinoma9Germ cell tumours3Other
(thymoma, mesothelioma)4

Clinical Presentation
- Sx: dyspnoea, cough, hoarseness, syncope, headaches
- Signs: facial oedema/plethora, ↑JVP, prominent superficial chest veins2, upper limb oedema
- Pemberton’s test: lifting arms above head for >1 min → facial plethora/cyanosis, ↑JVP and
inspiratory stridor
- If tracheal compression → airway compromise = oncological emergency

Ix
- Often not immediately life-threatening ∴ attempt to establish the underlying Δx and obtain
tissue biopsy (usually via bronchoscopy, though this may be hazardous, ∴ sputum cytology may
be a useful first step)
- CXR/CT
- Venography

Rx
- Initiation of high dose steroids often results in symptomatic relief (dexamethasone
emergency 4 mg/6 h IV otherwise 8 mg PO BD)
1 Due to leak of anti-thrombin 3 (AT3; ∴heparin, which acts via AT3, is insufficient thromboprophylaxis in these pts.)
2 In infra-azygos SVC obstruction, superficial abdominal veins may be dilated in addition
- Systemic Rx of underlying malignancy is often most successful Rx, particularly if
chemo-/radiosensitive e.g lymphoma, SCLC, germ cell tumours
- Intravascular balloon venoplasty + SVC stenting often results in good palliation