Practice Rational Imaging

Endovascular stenting to treat obstruction of the superior vena cava

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39562.512789.80 (Published 19 June 2008) Cite this as: BMJ 2008;336:1434
  1. Anthony F Watkinson, professor of radiology1,
  2. Tow Non Yeow, specialist registrar radiology 2,
  3. Clementine Fraser, fourth year medical student 1
  1. 1Peninsula Medical School, Royal Devon and Exeter Hospital, Exeter EX2 5DW
  2. 2Royal Devon and Exeter Hospital, Exeter EX2 5DW
  1. Correspondence to: A F Watkinson anthony.watkinson{at}rdeft.nhs.uk

    This article discusses the use of image guided endovascular stenting to treat obstruction of the superior vena cava

    The patient

    A 59 year old woman with a history of recurrent left sided breast cancer presented in October 2004 with bilateral arm and neck swelling, increasing shortness of breath, and headaches. We made a working diagnosis of obstruction of the superior vena cava. She had undergone surgery and external beam radiotherapy 13 years before for primary breast cancer. She subsequently underwent left mastectomy and chemotherapy for reoccurrence in 2000.

    What is the next investigation?

    Superior vena cava obstruction is usually diagnosed clinically, with the patient presenting with signs and symptoms related to venous congestion (box 1). Chest radiography usually demonstrates the abnormality with a widened mediastinum, although this may be normal.1

    Box 1 Signs and symptoms associated with obstruction of the superior vena cava234

    Early signs and symptoms
    Signs
    • Dilatation of the neck, arm, and chest wall veins

    • Oedema of the upper body, extremities, and face

    Symptoms
    • Cough and haemoptysis

    • Dysphagia

    • Chest pain

    • Dyspnoea

    Late signs and symptoms
    Signs
    • Severe respiratory distress

    • Cyanosis

    • Engorged conjunctiva

    • Convulsions and coma

    Symptoms
    • Severe headache and feelings of “tension in the head”—worse in the morning and on bending down

    • Visual disturbance

    Contrast enhanced computed tomography is the most commonly performed diagnostic imaging test. With multiplanar reformatting, this test allows accurate diagnosis and can show the extent, level, and cause of superior vena cava obstruction. The presence of dilated collateral vessels is highly suggestive of superior vena cava obstruction, with a sensitivity of 96% and specificity of 92%.5 6 7 Before the widespread use of computed tomography, upper limb venography was used to determine the level and extent of superior vena cava obstruction. However, it does not identify the cause of the obstruction and can overestimate the extent of venous occlusion as a result of shunting of blood through collaterals. Magnetic resonance venography is an alternative investigation that is increasingly being used. It has 100% sensitivity, …

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