Society For Clinical Vascular Surgery

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Diagnosis and Management of SVC Occlusion Manifesting Only With Recurrent, Unilateral Pleural Effusions
Galimat A. Khaidakova, MD, Sujin Lee, BS, Gail Peters, MD, Guillermo A. Escobar, MD.
Emory University, Atlanta, GA, USA

OBJECTIVES: A 28-year-old female with lupus nephritis and end-stage renal disease is readmitted on multiple occasions for shortness of breath and drainage of large, right-sided pleural effusions containing liters of fluid. These began shortly after getting a new right upper extremity AV fistula and was assumed to be from fluid overload. She had no evidence of swelling in her right arm or face, yet our hypothesis was that the effusions maybe related to a central stenosis and venous hypertension. We sought to find if this could be attributed to an uncommon manifestation of SVC syndrome.
METHODS: A right upper extremity venogram revealed that she had an occluded right innominate vein, and that the entire right upper extremity was draining into the phrenic veins via her large, internal mammary veins. It seemed plausible that this may be causing the recurrent right-sided effusions. Light criteria revealed that the pleural fluid was exudative, and an echocardiogram showed a very positive bubble study.
RESULTS: Conventional approaches for recanalization were unsuccessful using the upper extremities, right internal jugular and the femoral veins; ultimately requiring sharp (TIPS needle) recanalization with reentry and stenting. Her pleural fluid immediately decreased from approximately 1 liter a day to less than 150cc.
CONCLUSIONS: Despite not having any upper extremity swelling, central venous stenosis may rarely manifest only with large-volume pleural effusions. These can completely resolve with central recanalization or perhaps after decreasing the hydrostatic pressure (fistula ligation). We review the literature of this rare manifestation of venous hypertension.


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