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Case of the Month 01/08

Q: This 24 year old male presented to ED complaining of right arm swelling x 3 days. He had noted swelling of his R neck veins and some shoulder pain for 2-3 weeks but had no other symptoms. The exam was notable for jugular venous distension and RUE swelling.

What’s wrong with this picture?

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There is occlusion of the SVC. Note how the IV contrast is only seen around the periphery of the SVC due to the clot in the vessel.

Q: What are the imaging options which can be used to make this diagnosis?

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While a chest x-ray may have finding which suggest SVC syndrome (such as a widened mediastinum or hilar/mediastinal mass), the most useful imaging study is a chest CT with IV contrast. This study allows visualization of extravascular and intravascular tumors, thrombus formation within the SVC as well as collateral blood flow.

Q: How is this treated?

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The treatment of SVC syndrome depends on the underlying cause. In the case of an occluding thrombus, thrombolytics can be used to open the vessel. If a malignant mass is the cause of obstruction, radiation therapy and/or chemotherapy as well as steroids (in the case of steroid-responsive malignancies) may relieve symptoms by shrinking the compressing tumor. Other options which may be considered in select cases are endovascular stenting and SVC bypass surgery.

This patient was anticoagulated with heparin and then went to interventional radiology where tPA was administered via RUE catheterization. Afterwards, there was good flow seen on the venogram. He was then transitioned to lovenox and started on coumadin. To date his hypercoagulable work up has been negative and the etiology of his SVC occlusion unclear.