Contemporary management of superior vena cava syndrome

BACKGROUND: Superior vena cava (SVC) syndrome is a rare but severe medical condition owing to obstruction of the venous return to the heart through the innominate veins and the SVC. Lung cancer is the most common malignant cause, while central vein thrombosis owing to intravenous lines and pacemaker wires as well as mediastinal fibrosis are the frequent benign etiologies. METHODS: This review is based on an analysis of published literature reporting the results of endovenous management of SVC syndrome. RESULTS: Endovenous treatment, with balloon angioplasty and immediate stenting, has become the first line of treatment of all causes of symptomatic SVC syndrome. Various stents have been used, including balloon and self-expanding stents, woven, braided, and laser-cut nitinol stents, as well as open- and closed-cell designs. However, no single type has demonstrated superiority in comparative clinical studies. Evidence increasingly suggests that covered stents are safer for SVC obstruction, offering patency rates comparable with noncovered stents while decreasing the risk of lethal complications such as rupture and pericardial tamponade. For patients with malignant disease, fabric-covered stents may also decrease tumor ingrowth. Open surgery remains a viable option using spiral saphenous vein graft, femoral vein, and expanded polytetrafluoroethylene graft for those who are not candidates for endovascular interventions or fail after repeat interventions. CONCLUSIONS: Stent placement is a safe and effective first-line treatment for symptomatic SVC syndrome of both malignant or benign etiologies, with likely better outcomes and fewer complications associated with using covered stents.