Etiology of SVC Syndrome and its Role in Determining Best Treatment Approach - A Case Report

Introduction: Obstruction of the Super Vena Cava (SVC) can result in symptoms, such as facial plethora and swelling, and be due to a variety of underlying causes besides lung malignancies, the rates of which have changed over time; the underlying etiology is used to determine the best management strategy. Objectives: This case report aims to discuss the role of etiology in determining the best initial treatment for SVC syndrome (SVCS) and outlines the unique management for a patient that represents the changing demographics of SVCS causes. Case Presentation: A 73-year-old male with end-stage renal disease (ESRD) and metastatic carcinoma of the colon presented with swelling of the jaw, neck, and tongue. CT scan showed chronic thrombosis of the SVC and bilateral brachiocephalic veins. He had been receiving hemodialysis and chemotherapy through central venous catheters (CVCs) that transversed the SVC and terminated in the right atrium, resulting in venous stasis. Treatment involved double-barrel stent reconstruction of the SVC with temporary repositioning of the chemotherapy port catheter and exchange of the hemodialysis catheter. He experienced relief of symptoms and was able to continue his hemodialysis and chemotherapy appointments. Discussion: For cases of SVCS due to underlying lung malignancies, which has been and remains the most common cause, endovascular stenting is reserved as a palliative measure when treatment of a refractory malignancy fails to resolve the obstruction and for when symptoms are severe because most cases are not life-threatening. However, increased use of CVCs has caused a rise in SVCS due to thrombosis, for which stenting is the first-line treatment. Rare causes of SVCS that may require surgical correction include mediastinal fibrosis and thymomas. Of the few previously published case reports that depict bilateral SVC stenting and temporary repositioning of a CVC, they all describe cases due to lung malignancies or mediastinal fibrosis. Outlining this case presentation can increase awareness of thrombotic stenosis as an increasingly common cause of SVCS, which may occur in patients with a broader range of underlying conditions, ages, and life expectancies and require a wider array of physicians to be knowledgeable of management strategies. While stenting technology has improved dramatically since its inception, follow-up on stent patency will help determine if expanding treatment for lower acuity cases is beneficial. Conclusions: Endovascular stenting is the treatment of choice for thrombotic causes of SVCS, which is becoming more common due to the increased use of CVCs