• 80-90% caused by malignant tumors
• Benign tumors unusual
• The following thrombotic conditions are unusual causes:
• Trauma may produce acute obstruction
• Clinical presentation varies with: abruptness of onset, extend of occlusion, collateral pathways
• Venous pressure in arms/head: 200- 500 mm H2O
• Severity of symptoms correlates with pressure
• Cerebral edema can occur with complete obstruction
• Symptoms milder with patent azygous vein
• Azygous venous flow can increase to 35% of venous return (normal is 11%)
• Thrombus can propagate proximally to innominate and axillary veins
• 80-90% caused by malignant tumors
• Lung cancer 90% of malignant tumors
• Incidence is 3-5% in lung cancer patients
• Male:female ratio is 5:1
• Malignant SVC obstruction: 35% have thrombosis of innominate or axillary vein, 15% have complete caval obstruction without thrombosis, 50% have partial SVC obstruction
• Nasal congestion often earliest symptom
• Swelling in face, arms, shoulders
• Blue/purple discoloration of skin
• Headache, nausea, dizziness, vomiting, vision changes, drowsiness, stupor
• Cough, hoarseness, dyspnea (edema of vocal cords)
• Symptoms may be worse when patient lies on back or bends forward
• Esophageal varices may develop: GI bleeding
• Neck, arm veins may be visibly distended
• Fibrosing mediastinitis: Early morning edema of face and head
• Unilateral symptoms suggest ipsilateral occlusion
• Effort thrombosis or axillary vein and innominate vein obstruction from elongation and buckling of innominate artery in unilateral cases
• Chest film: May show right upper lobe lung lesion or right paratracheal mass
• Venography: Determines location and extent of obstruction
• Interosseous azygography: Useful to determine patency of azygous vein
• Aortography or CT scan: Excludes aortic aneurysm
• Physical exam
• Chest x-ray
• Chest CT scan
• Diuretics, restriction, head elevation prompt radiation or chemotherapy
• Often subsides at 7-10 days of treatment
• Fibrinolytics or anticoagulation can be considered but rule out metastatic cerebral metastases with CT/MRI
• Percutaneous stents allows good immediate drainage; long-term results unknown
• Tissue diagnosis often needed for therapy (via fine-needle aspiration, bronchoscopy, mediastinoscopy, or thoracotomy)
• Avoid operation if acutely obstructed due to high bleeding rate
• Surgical excision for incomplete obstruction
• For complete obstruction: Many improve without treatment, others require SVC bypass...
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