Vena Cava Syndrome Case Studies

NTRODUCTION

Superior vena cava syndrome (SVC) was first described in the 18th century in a patient with an aortic aneurysm caused by untreated syphilis [1]. By 1954, there were well over 250 cases documented in the literature of which approximately 40% were due to infectious causes such as tuberculous mediastinitis and syphilitic aneurysm [2]. Advances in medicine have eradicated many of the sequelae of the above diseases; however it appears more recently that the most common cause of SVC is malignancy [3]. One report states that 40% of SVC are due to non-malignant causes [4].
We present a case report of a young woman who presented to our emergency department with facial and right upper extremity swelling for two weeks after placement of
Two months prior to her presentation, she was admitted at an outside hospital for catheter-associated E. Coli bacteremia for which she received intravenous antibiotics and a subsequent exchange of her right subclavian dialysis catheter over a guide wire. Two weeks later, the patient again presented to the same outside hospital where she was still found to be bacteremic and her dialysis catheter was exchanged for a second time in which a left subclavian dialysis catheter was placed. After placement of the dialysis catheter, the patient had three incomplete dialysis sessions that were cut short due to patients complaint of chills and shortness of breath and was informed to go to the ED, however did not present until 9 days after her last dialysis
In cases of SVC caused by a malignant tumor, the management includes treatment of the cancer itself [24]. In those who appear to have life-threatening symptoms such as cerebral edema, airway obstruction to include stridor, or hemodynamic compromise, emergent intravascular stenting has shown to be safe and provides rapid relief; although in patients with small cell carcinoma, germ cell tumor or lymphoma, induction of chemotherapy has been shown to rapidly improve symptoms and the placement of a stent in such patients appear questionable. In patients with a thymoma or caval obstruction, mainstay treatment also includes chemotherapy followed by resection and stent placement should be avoided as it will interfere with tumor resection [3,24]. As is the case with our patient, when obstruction is caused by a thombus, anticoagulation should be initiated to help prevent propagation of the clot [23]. Intravenous unfractionated heparin should be initiated in the acute phase followed with the addition of Warfarin until the INR therapeutic (range between 2 to 3) for a minimum period of three months, although the benefit of short or long-term anticoagulation continues to be debated [8,25]. At the present, there are no studies to suggest superiorority between Warfarin versus low molecular weight heparin although Enoxaparin should be used with caution in patients with moderate renal impairment as this