Thoracic surgeons are routinely involved in the care of patients with superior vena cava obstruction (SVCO) and on occasion are called upon to resect the superior vena cava (SVC) in the course of treatment.1 This chapter summarizes overall management principles, indications for SVC resection, proper patient evaluation and coordination of care, intraoperative considerations, and postoperative care principles to ensure a successful outcome.
GENERAL PRINCIPLES AND GUIDELINES
General thoracic surgeons serve the patient with SVCO in three ways. First and most commonly, they are involved in the workup and diagnosis of the patient who presents with the spectrum of SVCO symptoms and a chest mass on radiographic studies. Second, a patient with severe symptoms from SVCO will need expedient management of life-threatening symptoms. Similar to approaching the patient with esophageal cancer, a “Captain of the Ship” is needed in both above situations, which often require the coordination of care of a multidisciplinary team (oncology, radiation oncology, interventional radiology, pathology), and nonoperative means of treatment will often be utilized (radiation, chemotherapy, stenting, thrombolytic therapy). Last, the thoracic surgeon may be called upon to resect the SVC for benign or malignant disease.
When called upon to evaluate the patient with SVCO, the thoracic surgeon should classify the patient by severity of the SVCO symptoms, achieve an expedient tissue diagnosis, coordinate the care of the multidisciplinary team of physicians, and evaluate if there is any role for therapeutic surgical intervention especially if the patient has a diagnosis of non–small-cell lung cancer (NSCLC), thyroid/thymic cancer, or germ cell neoplasm.
Approximately 35% of SVCO patients will be asymptomatic or have only mild symptoms of head and neck edema and cyanosis. Moderate to severe symptoms will be seen in 60% of patients manifested by increasing degrees of cerebral edema resulting in visual disturbances, headache, laryngeal edema, and diminished cardiac reserve. Patients will present with life-threatening symptoms 5% of the time.2
Table 86-1 presents the proposed grading system for superior vena cava syndrome.
Table 86-1GRADING SYSTEM FOR SVCO |Favorite Table|Download (.pdf) Table 86-1 GRADING SYSTEM FOR SVCO
|GRADE ||CATEGORY ||ESTIMATED INCIDENCE (%) ||DEFINITIONa |
|0 ||Asymptomatic ||10 ||Radiographic superior vena cava obstruction in the absence of symptoms |
|1 ||Mild ||25 ||Edema in head or neck (vascular distention), cyanosis, plethora |
|2 ||Moderate ||50 ||Edema in head or neck with functional impairment (mild dysphagia; cough; mild or moderate impairment of head, jaw, or eyelid movements; visual disturbances caused by ocular edema) |
|3 ||Severe ||10 ||Mild or moderate cerebral edema (headache, dizziness) or mild/moderate laryngeal edema or diminished cardiac reserve (syncope after bending) |
|4 ||Life threatening ||5 ||Significant cerebral edema (confusion, obtundation) or significant laryngeal edema (stridor) or significant hemodynamic compromise (syncope without precipitating factors, hypotension, renal insufficiency) |
|5 ||Fatal ||<1 ||Death |