**Title:** Understanding SVC Syndrome: Diagnosis, Management, and Advances **Author:** Dr. Jayabharathi, Specialist in Pulmonary Medicine **Audience:** Internal Medicine, Pulmonary Medicine, and Cardiothoracic and Vascular Surgery (CTVS) Professionals **Description:** SVC (Superior Vena Cava) syndrome presents a complex set of challenges in diagnosis and management. Join Dr. Jayabharathi, a distinguished specialist in Pulmonary Medicine, as she navigates through the intricacies of this condition in a comprehensive presentation tailored for internal medicine, pulmonary medicine, and cardiothoracic and vascular surgery (CTVS) professionals. In this session, Dr. Jayabharathi delves into the nuances of SVC syndrome, exploring its etiology, clinical manifestations, and diagnostic modalities with a focus on advanced imaging techniques. Drawing from her extensive clinical experience, she elucidates the intricacies of differential diagnosis and the importance of multidisciplinary collaboration in optimizing patient outcomes. Furthermore, this presentation encompasses contemporary approaches to the management of SVC syndrome, including both medical and interventional strategies. Dr. Jayabharathi discusses emerging therapies and recent advancements in surgical techniques, providing valuable insights for practitioners seeking to enhance their knowledge and skills in this critical area. Don't miss this opportunity to gain a deeper understanding of SVC syndrome from a seasoned expert in the field. Whether you're a seasoned practitioner or a resident-in-training, this presentation promises to enrich your clinical acumen and broaden your perspectives on managing this complex vascular condition.

1. SVC SYNDROME
DR JAYABHARATHI P
JUNIOR RESIDENT
DEPARTMENT OF PULMONARY MEDICINE
25/06/22

2. ANATOMY OF SVC

3. INTRODUCTION
Superior vena cava (SVC) syndrome results from any condition that leads to obstruction of blood flow through
the SVC.
Malignant obstruction can be caused by direct invasion of tumor into the SVC, or by external compression of the
SVC by an adjacent pathologic process involving the right lung, lymph nodes, and other mediastinal structures,
leading to stagnation of flow and thrombosis
Extra vascular by rigid pathology - Tumour (4T - thymoma , retrosternal thyroid ,T cell lymphoma and teratoma
Intravascular : thrombosis
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

4. JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

5. 1)azygous vein to ascending lumbar
veins to lumbar veins to IVC to RA
2) brachiocephalic vein (BCV) to
subclavian vein(SCV) to internal
thoracic vein continues as superior
epigastric vein to inferior epigastric vein
to external iliac vein ( EIV) to common
iliac vein(CIV) to IVC to RA
3) BCV to SCV to Axillary vein to
lateral thoracic vein to superficial
epigastric vein to great saphenous vein
(GSV)to femoral vein (FV ) to EIV to
CIV to IVC to RA
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

6. PATHOPHYSIOLOGY
Increased venous pressure
Oedema of upper extremity , head and neck
Cardiac output decreased ( intravascular compression )
Collateralisation ( extravascular )
Hemodynamic effect mainly due to mass effect of tumour rather than SVCO
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

7. MALIGNANT CAUSES BENIGN CAUSES
1)NON SMALL CELL CANCER (50%)
1)CENTRALVENOUS CATHETER,
PACEMAKER ,INDWELLING HEMODIALYSIS
CATHETER (25-30%)
2) SMALL CELL CANCER (25%)
2)RADIATION FIBROSIS ,MEDIASTINAL
FIBROSIS
3)LYMPHOMAS (10%) 3)INFECTION-SYPHILLIS ANDTB (50 yrs ago)
4)OTHER - THYMOMA , PRIMARY GERM CELL
NEOPLASM ,SOLID TUMOUR WITH
MEDIASTINAL METS (15%)
4)SARCOIDOSIS, RETROSTERNALTHYROID
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi:
10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

8. PAN COAST TUMOUR
COMPRESSING SVC
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

10. ONSET OF SYMPTOMS
Course of invasion or compression
Severity of luminal compromise
Recruitment of venous collaterals
Acute thrombosis of prior partial obstruction
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

11. ANATOMICAL
CLASSIFICATION
A)obstruction of SVC involving left and right
brachiocephalic veins .collaterals formed
multiple.
B) Supra -azygous : blood flow is directed to
the azygous through right superior intercostal
vein
C)azygous :chest wall collaterals
D) Infra -azygous :collaterals azygous and hemi
azygous

12. Based on location and severity

13. GRADING OF SEVERITY OF SVC SYNDROME
Based on symptoms

14. CLINICAL SYMPTOMS
Edema of upper extremity ,chest and face
Distension of neck and chest vein
Dyspnea
Headache and confusion ( cerebral edema )
Stridor
Cough
Hoarseness and dysphagia

15. PHYSICAL EXAMINATION
Arm edema
Cyanosis
Facial plethora
Elevated JVP
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

16. PEMBERTON SIGN
Exaggeration of edema and flushing
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

17. LIFETHREATENING ISSUES
Headache, dizziness and confusion (Cerebral oedema)
Compromised cardiac Hemodynamic
Blurred vision /papilledema
Oesophageal varices : bleeding
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

18. LABORATORY STUDIES
CBC
Coagulation studies
Tumour markers assay
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

19. LAB INVESTIGATIONS
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

20. INVESTIGATIONS
Sputum cytology ,pleural fluid cytology
Ct guided biopsy of peripheral lesion
Bone marrow biopsy in case of NHL
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

21. DIAGNOSTIC MODALITIES
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

22. CHEST X-RAY
Presence of collaterals
Mediastinal widening
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

23. AORTIC NIPPLE SIGN
Chest X-ray pa view
Represents left superior intercostal vein
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi:
10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

24. Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

26. CT VENOGRAPHY
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi: 10.4187/
respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

27. MRVENOGRAPHY
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi:
10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

28. SVCO ASSESSMENT
Bronchoscopy : EBB /CYTOLOGY/
EUS/EBUS
VATS
Peripheral LN biopsy
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

29. TREATMENT
Treat the underlying cause
GRADE 4 SVCO : emergency venogram /stenting
Thrombosis : anticoagulation
Tissue biopsy / staging
Tumour specific / stage specific treatment
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

30. Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi: 10.4187/
respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

31. Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi: 10.4187/
respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

32. SVCOTREATMENT
ALLEVIATE SYMPTOMS
PROPPED UP POSTION
INTRAMUSCULAR INTRAVENOUS ARM INJECTION AVOIDED
REMOVAL OF INTRAVASCULAR CATHETER
STEROIDS
EXTERNAL BEAM RADIOTHERAPY
DIURETICS
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi:
10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

33. Femoral approach or jugular or subclavian
9fr sheath
5000 IU Heparin IV
Catheter and steerable hydrophilic thermo guide wire
Stiff guidewire /catheter removed
Self expanding stent passed
Sinus XXL / wall stent - over sizing 10% to prevent migration
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi:
10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

34. Careful DILATATION of stent with angioplasty ballon
Short stenosis : ballon expanding stent : palmer /strecker stent
Sometimes bilateral stent : brachiocephalic and Svc
Most cases - unilateral stenting adequate
Re -Occlusion rate lower with unilateral
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

35. SVCO STENTING
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

36. SVCO STENTING
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011
May;56(5):653-66. doi: 10.4187/respcare.00947. Epub 2011 Jan 27. PMID: 21276318.

37. COMPLICATIONS
Pericardial tamponade
Pulmonary embolism
Stent migration to RA or PA
Pulmonary /cerebral and pericardial bleeding
Lepper PM, Ott SR, Hoppe H, Schumann C, Stammberger U, Bugalho A, Frese S, Schmücking M, Blumstein NM, Diehm N, Bals R, Hamacher J. Superior vena cava syndrome in thoracic malignancies. Respir Care. 2011 May;56(5):653-66. doi: 10.4187/respcare.009
Epub 2011 Jan 27. PMID: 21276318.

38. HEMOPERITONEUM STENT DISPLACEMENT

39. EXTERNAL BEAM RADIOTHERAPY
Before stenting era, XBRT was common
Combined CRT
IDIOTYPIC EFFECT
shortens overall treatment time
Reduced acceleration of tumour cell re growth
Concurrent better than sequential .
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

40. STEROIDTHERAPY
LYMPHOMA/ THYMOMA
POST RADIOTHERAPY
LARYNGEAL EDEMA
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

41. THROMBOLYTICS
LOCAL CATHETER DIRECTED THROMBOLYSIS
MECHANICAL ENDOVASCULAR THROMBECTOMY
ADJUVANT THROMBOLYTIC THERAPY AFTER SVC STENT FOR LONG TERM
CV THROMBOSIS :ANTICOGULATION BY 3-6 months
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

42. SURGICAL INTERVENTION
Replaced by Endovascular techniques
Locally invasive thymoma : surgery or multimodality treatment
NSCLC: Svc resection and repair
JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

43. JACC:CARDIOVASCULAR INTERVENTIONS VOLUME 13,issue 24;december2029,SUPERIOR CENA CAVA SYNDROME ,ABDUL HUSSAIN ET AL.,pages 2896-2910

44. SUMMARY
Clinical features are striking
Rarely requires emergency intervention
Common cause : malignancy
Tissue biopsy important
MDT approach important

45. SUMMARY
Hemodynamic compromise / laryngeal edema : emergency
Severe symptoms : Endovascular stenting ( 1B )
XBRT : not common
Radiotherapy followed by steroids to prevent edema (2C)
Malignancy --> stenting --> concurrent CRT --> prevents tumour re growth Svc

46. SUMMARY
NHL /GCT : chemotherapy
SCLC /NSCLC : CRT (1C )
Endovascular stent : long term anticoagulation (2C)/ dual platelet inhibition
RCT for most recommendations are lacking .

47. THANK YOU