Superior Vena Cava Syndrome Masquerading as Angioedema: A Chemotherapy Port Complication.

Superior vena cava (SVC) syndrome is a constellation of symptoms that occur secondary to external compression of the SVC, most commonly by a mediastinal malignancy. With the increased use of implanted cardiac devices and indwelling central venous catheters, SVC syndrome from a benign cause has become quite common. This report follows a 62-year-old female who was initially admitted to the critical care unit for treatment of angioedema without a history of malignancy but was found to have a surgically placed port used to treat her rheumatoid arthritis. Despite treatment of what was presumed to be angioedema, her symptoms failed to resolve. Imaging of the thorax revealed a venous thrombosis in the previously placed port. The port was subsequently removed, and the patient's symptoms hastily resolved. This case report underscores the importance of obtaining a thorough history, maintaining a broad differential diagnosis, and revising the differential when the patient's symptoms fail to improve.

Brachiocephalic Vein Reconstruction Following the Excision of a Large Suspicious Anterior Mediastinal Mass.

Superior vena cava syndrome (SVCS) is a clinical condition characterized by signs and symptoms resulting from the blockage or narrowing of the thin-walled superior vena cava (SVC). This obstruction can lead to significant morbidity and mortality. In this case, we report a 58-year-old patient who was diagnosed with SVCS due to a massive compressing anterior mediastinal mass leading to signs and symptoms of SVCS, including shortness of breath, dizziness, palpitations, and neck swelling, which was managed surgically by excision of the mass and reconstruction of the brachiocephalic vein using a synthetic graft.

"Rapid Atrial Swirl Sign": A Better Tool Than the Landmark Technique for Ensuring Correct Depth of Insertion of Central Venous Catheters.

INTRODUCTION: Central venous catheters (CVCs) are widely used in the management and resuscitation of critically ill patients in emergency departments and intensive care units. Correct depth of insertion of the CVC line is important to ensure uninterrupted flow, avoid complications, and monitor central venous pressure. Transthoracic echocardiography, with contrast enhancement, has been proposed as an alternative to chest X-ray in detecting central venous line positioning with high accuracy. Nevertheless, this method is not widely used due to some previous conflicting results and the cumbersomeness of the procedure. MATERIAL AND METHODS: After approval by the Institutional Ethics Committee, this prospective observational study was carried out in patients for whom a central venous line was warranted. The study was conducted in the Intensive Care Unit of a tertiary care hospital among 150 adult patients to compare the "Rapid Atrial Swirl Sign" (RASS) technique by transthoracic echocardiography and the landmark-based technique for ensuring accurate depth of central venous line placement. RESULTS: In this study, we found that the mean depth of insertion of the CVC for the Echocardiography RASS group (E) was 12.84 cm, while for the Landmark technique group (L), it was 12.02 cm. There was a significant difference between these groups, with a p-value of <0.05. We found that the majority of patients (98.63%) in Group E had the catheter tip in Zones 1, 2, and 3, while only 66.6% of patients in Group L had the catheter tip in similar zones. The mean standard deviation for zones on chest X-ray was 1.8 for Group E and 2.26 for Group L, with a significant difference between these groups (p-value <0.05). CONCLUSION: The RASS technique is superior to the landmark technique in ensuring the correct depth of the tip of the CVC. When confirmed by chest X-ray, it was found that most patients had the catheter tip in Zone 1, 2, or 3 using the RASS technique. This confirms that the RASS technique can minimize the requirement of resources and hasten the initiation of patient management in a timely manner, unlike the landmark technique, which requires chest X-ray confirmation before use.

Transcatheter stenting of superior vena cava to treat postoperative SVC syndrome in a child: a case report.

BACKGROUND: Superior vena cava (SVC) obstruction leading to SVC syndrome is an uncommon but potential complication of cardiac surgeries that involve dissection and anastomosis around the great vein. We present a case of iatrogenic SVC obstruction that was initially treated with transcatheter balloon angioplasty, which provided temporary relief, and ultimately resolved by stenting the affected segment. CASE PRESENTATION: The index case underwent total anomalous pulmonary venous connection (TAPVC) repair and presented 3 months after surgery with features of SVC obstruction. Initially, transcatheter balloon angioplasty was performed, providing relief from the obstruction; however, the condition recurred within one month. Finally, the patient was treated with percutaneous stenting of superior vena cava, through femoral venous route, using 8 mm × 30 mm balloon-expandable bare metal stent (Formula 418, Cook Medical, Bloomington, IN). Remarkable relief of obstruction was established with decrease in mean gradient across SVC-right atrium junction to 2 mm Hg (from 12 mm Hg before balloon angioplasty and 18 mm Hg before stenting). CONCLUSION: Percutaneous treatment for iatrogenic SVC obstruction developing after cardiac surgery appears to be effective. Close monitoring is required in the postoperative period for early diagnosis and timely intervention.

Unveiling a Unique Presentation of Superior Vena Cava Syndrome Succeeding a Traumatic Motor Vehicle Crash and Implantable Cardioverter-Defibrillator Lead Placement.

Superior vena cava (SVC) syndrome, once a rarity, has seen an uptick in cases with diverse origins. While this disease process is clinically diagnosable, imaging modalities and tissue biopsies further refine interventions. The clinical presentation includes but is not limited to edema of the arms, neck, and head, facial plethora, cyanosis, and or distention of subcutaneous vessels. SVC syndrome can be attributed to extrinsic compression or thrombosis in many cases. If symptoms are not life-threatening, the overall morbidity is based on the underlying root cause. Few cases have been reported with associated death due to epistaxis. However, the obstruction itself can be initially asymptomatic and then slowly progress over months to years. This case report highlights a distinct instance of SVC syndrome with notable risk factors: implantable cardioverter defibrillator placement and prior cardiac trauma status post-intervention.

A Superior Squeeze: Superior Vena Cava Syndrome Secondary to Small Cell Lung Cancer.

Superior vena cava (SVC) syndrome is an uncommon yet potentially fatal syndrome occurring after intrinsic or extrinsic compression to the SVC. While there are multiple emerging etiologies for this phenomenon, malignancy remains the most common. It is characterized by several symptoms including facial swelling, extremity swelling, shortness of breath, and headaches. We present the case of a 59-year-old female with a past medical history of cocaine abuse who was admitted for upper extremity swelling and facial edema. Imaging revealed a right suprahilar mass compressing a branch of the right pulmonary artery and SVC, in addition to bilateral segmental and subsegmental pulmonary emboli. She underwent an emergent biopsy and SVC stenting, with immunostaining revealing small cell lung cancer (SCLC). This case highlights a severe presentation of SVC syndrome caused by previously undetected SCLC.

Case Report: Endoluminal removal of a conical retrievable superior vena cava filter with a retraction hook attached to the wall.

We report the case of a 22-year-old male who underwent endoluminal surgery and was implanted an Option Elite filter in the superior vena cava (SVC) while the filter retraction hook was attached to the vessel wall. The patient requested to remove the filter after 155 days. Preoperative ultrasonography and CT examination revealed that the filter retraction hook was very likely to penetrate the SVC wall and its tip was very close to the right pulmonary artery. The SVC was not obstructed, and no thrombus was observed in either upper limb. After the filter retrieval device (ZYLOX, China) failed to capture the filter hook, we introduced a pigtail catheter with its tip partly removed and a loach guidewire, used a modified loop-snare technique to cut the proliferative tissues and free the hook, and finally removed the filter successfully by direct suspension of the guidewire. During this procedure, the patient experienced discomfort, such as chest pain and palpitations, but these symptoms disappeared when procedure completed. Repeated multiangle angiography revealed no contrast medium extravasation, no complications such as pericardial tamponade, pleural effusion, SVC haematoma formation, right pulmonary artery dissecting aneurysm, or intramural haematoma. We initially presented the modified loop-snare technique used to remove a conical superior vena cava filter (SVCF), so this method can be considered a practical and novel auxiliary technique for successful filter retrieval.

Metastatic Melanoma Causing Superior Vena Cava (SVC) Syndrome: A Case Report of a 65-Year-Old Male With a History of Multiple Myeloma and Melanoma.

A 65-year-old male with a history of multiple myeloma and melanoma presented to the hospital with shortness of breath and lightheadedness. He was subsequently diagnosed with mild superior vena cava (SVC) syndrome due to a metastatic melanoma mediastinal mass. While melanoma frequently metastasizes to the lungs, the occurrence of SVC syndrome resulting from metastatic melanoma is exceedingly rare compared to other malignancies like lung cancer. Consequently, data on the incidence or prevalence of SVC syndrome caused by metastatic melanoma are sparse and variable. This case particularly underscores the rarity of melanoma causing SVC syndrome, as evidenced by the oncology team's request to perform a second biopsy to confirm the diagnosis. This case also highlights the need for a tailored diagnostic and management approach, providing valuable insights into the diverse presentations of melanoma and enriching the medical literature on this subject.

EBUS-TBNA diagnosis of mediastinal melioidosis in patient presented with lymphadenopathy and SVC thrombosis: A rare manifestation in non-diabetic patient.

Melioidosis is a tropical infectious disease that ranks as northeastern Thailand's third most common infectious cause of death. The manifestations of melioidosis vary depending on the organs involved and often resemble malignancy and tuberculosis. We present a case of an atypical melioidosis presentation in a patient with low-grade fever and facial swelling without any risk factors. Chest CT revealed a 3.3-cm heterogeneous enhancing right lower paratracheal lymph nodes with thrombosis of the superior vena cava and azygos vein. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph node was performed, and Burkholderia pseudomallei was identified through lymph node culture. The patient underwent a three-week intravenous course of ceftazidime and a 12-week oral course of trimethoprim-sulfamethoxazole. Oral anticoagulation was also administered. Follow-up computed tomography of the thorax after completion of treatment revealed no residual lymphadenopathy and thrombosis.

Unveiling the culprit: Exploring malignant thrombotic superior vena cava obstruction.

This case image describes the complex proposed etiologies of a case of superior vena cava syndrome. Hence, different diagnostic and therapeutic modalities are needed in a multidisciplinary team approach.

Lead Extraction and Baffle Stenting in a Patient with Transposition of the Great Arteries.

This case report discusses a 42-year-old male with dextro-transposition of the great arteries (D-TGA) status post Mustard repair and sick sinus syndrome status post dual-chamber pacemaker implant, who developed symptomatic superior vena cava (SVC) baffle stenosis. He was treated with a combined pacemaker extraction and subsequent SVC baffle stenting. The case highlights the complexities of treating SVC baffle stenosis in the presence of cardiac implantable devices and demonstrates the efficacy of this combined approach. Furthermore, the authors delve into the intricacies of D-TGA, its surgical history, and the long-term complications associated with atrial switch procedures.

Wide en-bloc thymectomy and venous axis reconstruction in Masaoka stage IIIB thymoma: a case report and literature review.

Thymomas are rare tumors originating from thymic tissue and rarely metastasize. They can be diagnosed either incidentally or symptomatically when compressing or invading nearby structure. A 36-year-old man presented with significant high-grade fever, chest pain that worsens upon lying down, and dyspnea. A chest X-Ray and computed tomography followed by biopsy confirmed the diagnosis of thymoma. The management included chemotherapy cycles, followed by surgery. Pericardiectomy was performed with en-bloc thymectomy and partial resection of the infiltrating lung. Venous drainage was restored by 8/16 mm inverted bifurcated brachiocephalic-superior vena cava Dacron bypass. The pericardium was reconstructed by a synthetic Dacron patch, and the right diaphragm metastasis was resected. Neoadjuvant chemotherapy was initiated. After 3 months of follow-up, no recurrence was evidenced by computed tomography.

Management of malignant superior vena cava syndrome.

Superior vena cava (SVC) syndrome occurs due to obstructed blood flow through the SVC. It can present clinically on a spectrum, between asymptomatic and life-threatening emergency. Patients commonly report a feeling of fullness in the head, facial, neck and upper extremity edema, and dyspnea. On imaging, patients commonly have superior mediastinal widening and pleural effusion. The majority of cases are due to malignant causes, with non-small cell lung cancer, small cell lung cancer, and lymphoma the most commonly associated malignancies. When evaluating patients, a complete staging workup is recommended, as it will determine whether treatment should be definitive/curative or palliative in intent. If the patient requires urgent treatment of venous obstruction, such as in the cases of acute central airway obstruction, severe laryngeal edema and/or coma from cerebral edema, direct opening of the occlusion by endovascular stenting and angioplasty with thrombolysis should be considered. Such an approach can provide immediate relief of symptoms before cancer-specific therapies are initiated. The intent of treatment is to manage the underlying disease while palliating symptoms. Treatment approaches most commonly employ chemotherapy and/or radiation therapy depending on the primary histology. Mildly hypofractionated radiation regimens are most commonly employed and achieve high rates of symptomatic responses generally within 2 weeks of initiating therapy.

Should SVC flow be a routine measure when performing targeted neonatal echocardiography? A narrative review.

Superior vena cava is commonly used in neonatal hemodynamics and is suggested to be the best available non-invasive marker for systemic circulation in preterm infants. Inter- and intra-observer variability remain to be an issue. Its association with neonatal outcomes is has not been established. This is a narrative review about this marker, its use, and its potential pitfalls. OBJECTIVE: This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes. SOURCES: Literature revie mainly PubMED. SUMMARY OF THE FINDINGS: SVC flow measurement has some limitations and pitfalls. CONCLUSIONS: SVC flow association with neonatal outcomes, still needs to be established in further research.

Thymic en-bloc resection with veins: case demonstrations and review of the literature.

Locally invasive thymic neoplasms are challenging clinical scenarios and typically require a multidisciplinary approach. The involvement of major mediastinal veins such as the superior vena cava (SVC) used to be a contraindication to surgery, but with improved surgical technique and outcomes, this paradigm has shifted. In some situations, complex resections and reconstructions may be indicated and required to improve the long-term outcome of these patients. We report two of our cases along with a current review of literature. We also describe the preoperative workup, operative techniques, postoperative management, complications, and outcomes of patients with invasive thymic neoplasms that involve the mediastinal veins. Our first case describes a patient who was diagnosed with a thymoma extending from the diaphragm to the base of the neck that was also encasing major vascular structures including the SVC and left innominate vein. Our second case describes a patient who was also diagnosed with a large anterior mediastinal mass encasing the great veins and invading the chest wall. We describe the management of these patients and then delve deeper into operative techniques including SVC resection and reconstruction. We describe the types of conduits that can be used and complications to be mindful of when clamping the great veins, such as the SVC. Improvements in conduit materials and neoadjuvant and adjuvant therapies over the years have made it more feasible for patients with invasive thymic neoplasms to undergo surgery.

Superior vena cava obstruction and cardiovascular implantable electronic devices-a new era of leadless devices.

Cardiovascular implantable electronic devices (CIEDs) such as pacemakers and implantable cardioverter defibrillators require the placement of a transvenous lead through the superior vena cava (SVC), which can be difficult if there is stenosis or obstruction of the SVC. Moreover, SVC syndrome may occur after the lead is inserted even if the SVC was intact before the implantation. Therefore, there is need of an appropriate strategy for handling stenosis or obstruction of SVC during lead placement. In addition, advances are being made in CIEDs that do not require transvenous leads, and thus CIEDs without a transvenous lead should be considered depending on the indications and urgency of the particular case. This manuscript is divided into (I) device therapy for patients with SVC obstruction and (II) therapeutic strategy for SVC obstruction after lead implantation. In patients with SVC syndrome, treatment of the SVC occlusion should be based on the individual pathophysiology, and depending on the indications and urgency of the case, treatment with CIEDs that do not require transvenous leads should be considered. Further data must be accumulated to clarify the long-term prognosis of device implantation after treatment of SVC occlusion. In addition, transvenous lead extraction is now widely used for device-related SVC obstruction, and this procedure also merits further accumulation of data.

Persistent left-sided SVC: An incidental finding during Port-A-Cath placement.

Port-A-Cath (port), a single-lumen, tunneled catheter, is routinely placed into the superior vena cava (SVC) for cancer patients undergoing chemotherapy. We present a case of a port placement in which variant anatomy was discovered during the fluoroscopy-guided procedure and confirmed by venogram of a persistent left-sided SVC (PLSVC). Upon further investigation into the patient's previous computed tomography (CT) scans, the diagnosis was further confirmed. Patients with PLSVC are typically asymptomatic; however, some are associated with increased congenital heart defects (CHD), which increase the risk for complications during invasive procedures. Diagnosing PLSVCs and knowing the clinical implications/complications can improve patient care; by not removing catheters unnecessarily and being prepared to treat/minimize complications.

Stents migration into right atrium from severely calcified superior vena cava in a hemodialysis patient.

Vascular calcification is common among hemodialysis patients. In this report, we presented a case of superior vena cava (SVC) stent migration during endovascular angioplasty in a 50-year-old female hemodialysis patient with severe SVC calcification. The stent migration was refractory to the deployment of a second anchor stent, which shortly resulted in pericardium tamponade and was successfully rescued by emergent thoracotomy. The potential role of vascular calcification as a risk factor to stent migration was discussed. Patients with severe vascular calcification receiving endovascular angioplasty might need a careful risk screening for stent migration.

Downhill Varices and Apical Lung Cancer Without Superior Vena Cava Syndrome.

A 75-year-old woman with hypertension, dyslipidemia, thalassemia trait, osteoarthritis of the knees, and hyperthyroidism presented with bloating, abdominal discomfort, and change in stool caliber underwent an esophagogastroduodenoscopy. The esophagogastroduodenoscopy revealed varices at the middle of esophagus, which were diagnosed to be downhill esophageal varices (DEVs). DEVs occur mainly from the superior vena cava (SVC) obstruction; however, in the absence of obstruction, angiogenesis and thrombosis could be the etiology. In our patient, computed tomography showed a pulmonary nodule located at periphery of the right upper lung without SVC contact nor obstruction. The nodule was later proven to be an adenocarcinoma. Thus, our patient showed the possibility that adenocarcinoma of the lung might associated with the DEV through a mechanism other than SVC obstruction. Recognition and differentiation of DEV from other benign venous blebs of the esophagus are important, and once detected, further investigation with computed tomography of the chest is recommended.