The Role of Extracorporeal Membrane Oxygenation in the Anesthetic Management of Superior Vena Cava Syndrome: Is it Time to Use a Scoring System?

Abstract

SUPERIOR VENA cava (SVC) syndrome is characterized by a mechanical obstruction to the SVC, decreasing preload to the heart and causing the constellation of neck vein distention, facial, and upper extremity edema, and sometimes cerebral edema. 1 Kishi K Sonomura T Mitsuzane K et al. Self-expandable metallic stent therapy for superior vena cava syndrome: Clinical observations. Radiology. 1993; 189: 531-535 Crossref PubMed Scopus (109) Google Scholar ,2 Qanadli S El Hajjam M Bruckert F et al. Helical CT phlebography of the superior vena cava: Diagnosis and evaluation of venous obstruction. Am J Roentgenol. 1999; 172: 1327-1333 Crossref PubMed Scopus (53) Google Scholar Malignancy has been the historic cause of SVC syndrome, although there has been a shift toward nonmalignant etiologies accounting for up to half of cases. 3 Nossair F Schoettler P Starr J et al. Pediatric superior vena cava syndrome: An evidence-based systematic review of the literature. Pediatri Blood Cancer. 2018; 65: e27225 Crossref PubMed Scopus (12) Google Scholar ,4 Siegel Y Kuker R. Superior vena cava obstruction in hemodialysis patients: Symptoms, clinical presentation and outcomes compared to other etiologies. Ther Apher Dial. 2016; 20: 390-393 Crossref PubMed Scopus (5) Google Scholar Malignancies arising in the anterior mediastinum are well-known to cause SVC syndrome by direct tumor invasion or SVC compression. These typically advanced tumors also may cause external compression of the respiratory tract, complicating mechanical ventilation and the provider's options for securing an airway sufficient for ventilation and oxygenation. 5 Straka C Ying J Kong F et al. Review of evolving etiologies, implications and treatment strategies for the superior vena cava syndrome. Springerplus. 2016; 5: 229 Crossref PubMed Scopus (43) Google Scholar Although general anesthesia generally is considered high risk, it routinely is required for surgical biopsy, before resection, or for palliative treatments. The imminent risks of cardiovascular and respiratory collapse during induction of general anesthesia pose a real challenge for the anesthesiologist, and may require extracorporeal membrane oxygenation (ECMO) perioperativelt to safely manage patients with SVC syndrome.