INTRODUCTION: Superior Vena Cava (SVC) obstruction in a common complication of small cell lung cancer. However, cardiac arrest in a patient with SVC obstruction during flexible bronchoscopy has not been described in literature.
CASE PRESENTATION: 54-year-old African-American female was referred to our clinic with a history of hemoptysis two weeks ago and abnormal chest X-ray. History was positive for progressive dyspnea on exertion, 15 lb weight loss on the background of 30 pack years smoking history. Past medical history was significant only for hypertension. Review of systems was non-contributory. Examination showed normal vitals, hoarse voice, asymmetrical neck with swelling greater on right side, non-pulsatile distended neck veins, decreased breath sounds in the right upper lung field with occasional crackles. She did not distended veins on chest wall. Lab was only significant for mild normocytic anemia. Chest X-ray and CT scan of the chest showed right upper lobe perihilar mass with extension into the anterior and superior mediastinum, and superior vena cava obstruction. Bronchoscopy was done at forty-five degrees under monitored anaesthesia care. Both upper and lower airway were grossly edematous, there was a mass in the upper lobe bronchus with complete occlusion. Following the third biopsy of this lesion patient had asystolic cardiac arrest, was resuscitated successfully. During the first code patient intravenous access in the left upper extremity had reverse blood flow into the line. Femoral line was placed, She was intubated, and then had second code. After successful resuscitation she was admitted to intensive care unit. Though the codes were short of less than two minutes each, patient suffered anoxic brain injury requiring prolonged ventilation, tracheostomy and percutaneous endoscopic gastrostomy. Biopsy result confirmed small cell lung cancer.
DISCUSSION: Superior vena cave syndrome (SCVS) is a constellation of signs and symptoms caused by obstruction of blood flow secondary to external compression, invasion, constriction or thrombosis of the SVC. SVC obstruction leads to increased venous pressure and edema of the neck, arms, upper chest, and head causing increased intracranial pressure. Patient may present with headache, syncope or presyncope, nausea and vomiting, hoarseness, dysphagia, cough, dyspnea and chest pain. Severity of symptoms depend on the time course of obstruction. As obstruction develops, venous collaterals develop to find alternate pathways for venous return to the right atrium. In the post-antibiotic era malignancy remains the commonest etiology. Lung cancer is the commonest malignancy. SVCS is most common with small cell lung cancer as it grows rapidly in central airways. CT chest, Magnetic Resonance imaging /Magnetic Resonance Venography are the investigation of choice which provides information on location, possible etiology, extent of collaterals and guide biopsy attempts. Bronchoscopy is safe in SVCS with adverse event of less than 1%. Tissue diagnosis should take priority before initiating treatment as only a handful of deaths directly related to SVCS has been described. Treatment is tailored to etiology. Emergent radiotherapy and stent placement is limited for patients with stridor, severe laryngeal edema, and coma from cerebral edema. Steroid role is limited to steroid-responsive tumors and patient receiving radiotherapy who has severe laryngeal edema. Thrombolytic s and thrombectomy can be of value in thrombus associated SVCS. The average life expectancy among patients who present with malignancy-associated SVCS is approximately six months, however, there is wide variability depending on the underlying malignancy.
CONCLUSIONS: We believe that one of the reasons for our patient’s asystolic cardiac arrest was an acute on subacute SVC obstruction with significant rise in intracranial pressure. Bronchoscopy is not contraindicated in SVCS and there has not been any case report to the best of our knowledge of cardiac arrest as an adverse event during this procedure in a patient with SVCS.
Reference #1 [Superior vena cava syndrome]. Taguchi J, Kinoshita I, Akita H.Gan To Kagaku Ryoho. 2011 Apr;38(4):518-23. Japanese. PMID:21498977
Reference #2 Superior vena cava obstruction: diagnosis, management and outcome. Adegboye VO, Ogunseyinde AO, Obajimi MO, Brimmo AI, Adebo OA.East Afr Med J. 2008 Mar;85(3):129-36.
Reference #3 Obstruction of the superior vena cava. Lochridge SK, Knibbe WP, Doty DB. Surgery. 1979 Jan;85(1):14-24.
DISCLOSURE: The following authors have nothing to disclose: Vishal Poddar, Alicia Thomas
No Product/Research Disclosure Information