Superior vena cava syndrome medical therapy

Superior vena cava syndrome is a medical emergency and requires prompt treatment. The treatment of superior vena cava depends on the etiology of the obstruction, the severity of the symptoms, the prognosis of the patient, patient preferences, and goals for therapy.

Patients with sufficient collateral blood flow and minimal symptoms may not need treatment. If the lesion is above the azygous vein or if the onset of superior vena cava occlusion is slow enough to allow sufficient collateral circulation, the symptoms and signs may stabilize and the patient may be comfortable enough to forgo further therapy.^[1]

Short-term palliation of a symptomatic patient who does not want aggressive treatment may be achieved by elevating the head and using corticosteroids and diuresis. There are no definitive studies that prove the effectiveness of steroids, although they are potentially useful to treat respiratory compromise. Diuretics may give symptomatic relief of edema but can ultimately cause systemic complications, such as hypernatremia.^[2]

Palliative measures include:

• Glucocorticoids (dexamethasone 4mg every 6 hours)
• Head elevation to decrease hydrostatic pressure and cerebral edema
• Remove indwelling catheter (if secondary to thrombosis)
• Consider loop diuretics (thiazide diuretics)
• Anticoagulation benefit not clear, although some recommend thrombolysis followed by anticoagulation

Chemotherapy is the treatment of choice for sensitive tumors such as lymphoma or small cell lung cancer. Superior vena cava syndrome does not appear to be an independent prognostic factor, and its presence should not change the treatment approach. Rapid initiation of chemotherapy can result in complete and partial response rates of the superior vena cava syndrome of more than 80% in small cell lung cancer patients.^[2]

In most cases, superior vena cava syndrome arises when a thrombus forms in a partially occluded vein. In patients with a documented thrombus in the superior vena cava, treatment may include thrombectomy, with or without tissue plasminogen activator or other thrombolytic agents such as streptokinase or urokinase.

• Most adult patients who develop superior vena cava syndrome have lung cancer, the treatment support measures that are developed for superior vena cava syndrome should take into account overall prognosis and other symptoms caused by the malignancy.

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