Too Close for Comfort: Superior Vena Cava Syndrome Due to Mediastinal Mass

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Am J Respir Crit Care Med

Keywords

acetarsol, apixaban, corticosteroid, adult, anticoagulant therapy, brachiocephalic vein, case report, CD4 CD8 ratio, clinical article, computed tomographic angiography, conference abstract, deep vein thrombosis, diagnosis, disease course, drug therapy, endobronchial ultrasonography, fine needle aspiration biopsy, hospital readmission, human, jugular vein, male, mediastinum mass, middle aged, oral drug administration, patient compliance, sarcoidosis, subcutaneous drug administration, superior cava vein, superior cava vein syndrome, thrombectomy, treatment outcome, upper limb, vein thrombosis

Abstract

Superior vena cava (SVC) syndrome is commonly associated with malignancies, but it can also arise from non-malignant causes like vascular abnormalities or sarcoidosis. We present a case of a 41-year-old male with SVC occlusion and thrombosis secondary to a right lower lobe (RLL) mass. The patient initially presented with symptoms of an enlarged neck vein and upper extremity swelling. CT angiography (CTA) of the chest and neck revealed a 4.6 x 3.9 x 6.2 cm calcified right pre- and paratracheal mass, along with a 5.1 x 3.2 x 4.2 cm mass-like opacity in the RLL. Endobronchial ultrasound (EBUS) with biopsy and fine needle aspiration (FNA) ruled out malignancy, but a high CD4/CD8 ratio raised suspicion for sarcoidosis. Further imaging revealed acute deep venous thrombosis (DVT) involving multiple right upper extremity veins, extending into the brachiocephalic vein and causing SVC compressionInitial management with Eliquis (apixaban) was instituted for the SVC thrombus, but the patient experienced recurrent symptoms, including worsening upper extremity pain and swelling, prompting readmission. Given the persistence of symptoms despite anticoagulation therapy, thrombectomy with possible stenting was recommended as the next step. While corticosteroids are typically used to manage sarcoidosis-related SVC syndrome by reducing inflammation and mass effect, the extent of vascular thrombosis warranted interventional measures (1).This case illustrates the diagnostic complexity of a calcified mediastinal mass leading to SVC syndrome with a possible sarcoid etiology, compounded by significant vascular thrombosis. The patient's clinical course underscores the challenges of managing SVC syndrome in the setting of sarcoidosis and DVT, as well as the importance of timely intervention. Multidisciplinary collaboration involving pulmonology, interventional radiology, and vascular surgery was crucial in optimizing patient outcomes. This case also highlights the role of patient compliance in the successful management of chronic vascular conditions.

Volume

211

Issue

Supplement 1

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