| Superior Vena Cava Syndrome |
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Facial edema and subcutaneous vein engorgement in head, neck and chest.
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Complete obstructions additionally present with plethora, dyspnea, orthopnea, cough, hoarseness, cyanosis, headache, seizures and, eventually, coma.
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Chest X-ray: mediastinal widening (66%) or pleural effusions (25%).
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CT with contrast: gold standard.
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Elevate head to minimize venous congestion.
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Medical and radiation oncology consultation should be expedited to initiate systemic therapy because reducing tumor bulk is definitive.
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Urgent thrombolysis, thrombectomy, or placement of a venous stent may alleviate stridor and hemodynamic compromise although vascular intervention risks luminal perforation.
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Diuretic use should be minimized.
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| Venous Thromboembolism |
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Chief complaints of shortness of breath, unilateral leg swelling, or reduced oxygenation on pulse oximetry.
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D-dimer levels are not informative: they can be elevated generally in cancer patients.
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CT angiography of the chest is the definitive study because not only can it rule out other processes but it can also confirm right ventricular strain.
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If IV contrast is contraindicated, a ventilation-perfusion scan along with cardiac echography is appropriate.
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Systemic thrombolysis is indicated for massive PE with hemodynamic compromise except in patients with a high risk of bleeding, for whom catheter-assisted thrombectomy is indicated.
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Factor Xa inhibitors are noninferior to low-molecular-weight heparin, with apixaban demonstrating fewer major bleeding events.
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The benefit of thromboprophylaxis has not been demonstrated.
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Patients with small, incidental PEs and no functional or vital sign compromise are eligible to initiate anticoagulation in the ED then be safely discharged home with close follow-up.
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