Superior Vena Cava Syndrome with Endovascular Stenting

Obstruction of the superior vena cava is most often caused by bronchogenic carcinoma. In cases of acute occlusion, edema of the head, neck, and upper extremities produces dramatic symptoms and, in the absence of collateral venous drainage, may lead to death.

In November 2001, a 51-year-old woman presented with severe facial and neck edema, 4-pillow orthopnea, and severe headache. She was a heavy smoker. Computed tomography (CT) of the chest with contrast medium (Fig. 1) revealed a large mass that occupied the anterior and superior mediastinum and encircled the superior vena cava (SVC). Anterior and posterior compression had reduced the SVC (black arrow) to almost complete obstruction. Because of the fast progression of symptoms and the central location of the tumor, we suspected small-cell lung cancer. This diagnosis was confirmed by histologic examination of a CT-guided biopsy.

Although chemotherapy and radiation therapy are usually effective in reducing such a tumor, their action would have been too slow for this situation. Therefore, we proceeded with endovascular stenting to provide the fastest regression of the patient's severe symptoms. ^1,2 The right femoral vein was cannulated, and angiography of the superior vena cava was performed by injecting contrast medium at the level of the right axillary vein (Fig. 2). Results showed a large filling defect of the SVC (arrowhead) and the absence of collateral veins. The entire length of the SVC was stented with a Wallstent® endoprosthesis (Boston Scientific Co.; Natick, Mass), 12 mm in diameter and 90 mm long (Fig. 3). Postoperative angiography showed the SVC to be widely patent. The patient's symptoms resolved within 24 hours, and she was discharged for radiation treatment and chemotherapy at the outpatient clinic.