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For further information, see CMDT Part 12-17: Superior Vena Caval Obstruction

Key Features

  • A rare disorder caused by partial or complete obstruction of the superior vena cava

  • Most frequent causes

    • Neoplasms, such as carcinoma of the lung with direct extension (> 80%), lymphomas, primary malignant mediastinal tumors

    • Chronic fibrotic mediastinitis, either of unknown origin or secondary to tuberculosis, histoplasmosis, pyogenic infections, or drugs (especially methysergide)

    • Deep venous thrombosis

    • Aneurysm of the aortic arch

    • Constrictive pericarditis

Clinical Findings

  • Swelling of the neck and face and upper extremities

  • Headache

  • Dizziness, stupor, syncope, cough

  • Visual disturbances

  • Bending over or lying down accentuates symptoms

  • Dilated anterior chest wall veins and/or collateral veins

  • Facial flushing

  • Brawny edema and cyanosis of the face, neck, and arms

  • Cerebral and laryngeal edema

  • Venous pressure

    • Elevated in the arm (often > 20 cm H2O)

    • Normal in the leg


  • Venous pressure

    • Elevated (often > 20 cm H2O) in the arm

    • Normal in the leg

  • Bronchoscopy is often performed, since lung cancer is a common cause

  • Transbronchial biopsy is relatively contraindicated because of venous hypertension and the risk of bleeding

  • Chest radiographs and a CT scan can define the location and often the nature of the obstructive process

  • Contrast venography or magnetic resonance venography (MRV) will map out the extent and degree of the venous obstruction and the collateral circulation

  • Brachial venography or radionuclide scanning following intravenous injection of technetium Tc-99m pertechnetate demonstrates a block to the flow of contrast material into the right heart and enlarged collateral veins

  • These techniques also allow estimation of blood flow around the occlusion as well as serial evaluation of the response to therapy


  • Conservative measures such as elevation of the head of the bed and lifestyle modification to avoid bending over are useful

  • Balloon angioplasty of the obstructed caval segment combined with stent placement

    • Procedure of choice

    • Provides prompt relief of symptoms

  • Occasionally, anticoagulation is needed, while thrombolysis is rarely needed

  • Urgent treatment for neoplasm consists of

    • Cautious use of intravenous diuretics

    • Mediastinal irradiation (starting within 24 hours)

    • Intensive radiation therapy combined with chemotherapy palliates the process in about 90% of patients

    • In patients with a subacute presentation, radiation therapy alone usually suffices.

    • Chemotherapy is added for lymphoma or small-cell carcinoma

  • In cases where the thrombosis is secondary to an indwelling catheter, thrombolysis may be attempted

    • Clinical judgment is required since a long-standing clot may be fibrotic and the risk of bleeding can outweigh the potential benefit

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