Superior vena cava obstruction (SVCO)

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Red flags

• Airway compromise from glottic/upper-airway oedema (stridor) is rare but life-threatening — the main reason an SVCO patient comes to ICU. Intubate early; this can be anatomically difficult (venous engorgement of the airway) — call the most experienced laryngoscopist and have a surgical airway plan.
• Cerebral venous congestion → confusion, depressed GCS, headache, papilloedema, seizures — reflects cerebral oedema from raised intracranial venous pressure. Treat by decompressing the SVC (stent).
• Rarely a true emergency unless airway compromise or cerebral venous congestion — most cases are subacute (days-weeks) and can be investigated electively.
• DO NOT place central venous catheters via upper-body routes (IJ/subclavian) — the SVC is obstructed/under high pressure, access is difficult, and lines thrombose or perforate. Use the FEMORAL route.
• SVC stenting provides rapid relief (clinical improvement within 48 hours in about 85% of a lung-cancer cohort; relief in 95% of pooled series) and is indicated for severe symptoms (airway/cerebral compromise), symptomatic recurrent disease, or non-malignant causes. For malignant SVCO, treat the underlying cancer with chemo/radiotherapy — stenting is for relief of severe/refractory symptoms.
• A tissue diagnosis is required before definitive cancer treatment — obtain biopsy (sputum, bronchoscopy, mediastinoscopy, lymph node) BEFORE starting steroids or radiotherapy wherever possible, because steroids can obscure lymphoma histology.
• Small-cell lung cancer and lymphoma are chemosensitive and respond within days to weeks — stenting is often NOT needed if the tumour is treated. NSCLC and other solid tumours respond slowly — stenting more often needed.
• Benign SVCO (thrombosis from catheter/pacemaker, fibrosing mediastinitis) has a normal life expectancy — stenting is now first-line for symptomatic benign SVCO, with long-term anticoagulation.