Superior vena cava syndrome: Still a medical dilemma

Purpose The purpose of this report is to highlight the dilemma and the associated clinical implications in treating a patient with superior vena cava syndrome (SVCS) with a coexisting coagulophathy. Clinical Features: This case report describes a post-bone marrow transplant patient who was admitted to our ICU because of bronchiectasis complicated with nosocomial pneumonia. Following the recovery from pneumonia and long ventilatory support, he developed superior vena cava syndrome (SVCS) due to mediastinal lymphadenopathy. The diagnosis was delayed due to associated confounding clinical factors. Due to the rapid deterioration in patient's condition, the immediate tissue diagnosis of mediastinal lymph nodes and re-canalization of superior vena cava by stenting was not done though it was, our priority. He had many other medical problems as well such as thrombocytopenia, deranged coagulation profile, old cerebral infarction with hemiplegia, seizure disorder and cardiac arrhythmias that complicated the treatment plan. Ultrasonography (USG) guided biopsy followed by stenting of the SVC was done after discussing the risks and benefits with patient's relatives. But, he had bleeding from biopsy site due to deranged coagulation profile. He was not given any anticoagulants. Within 24 hours, the stent was blocked by clot that was diagnosed by the deteriorating clinical features and a repeat CT scan. Then he was given Enoxaparin in therapeutic dose and the clot cleared within a day, possibly partly due to Enoxaparin and partly coagulopathy. Conclusion: Meticulous care should be practiced in deciding the appropriate treatment of SVCS especially when it is associated with other complicating medical problems particularly coagulopathy.