SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Superior Vena Cava (SVC) syndrome is caused by obstruction of the SVC, impeding venous drainage into the right atrium. SVC syndrome is responsible for a rare subset of acute upper gastrointestinal bleeding from downhill esophageal varices.(1) We present a case of hemoptysis thought to be due to bronchial vein bleeding by a similar mechanism. CASE PRESENTATION: A 23 year old male with end stage renal disease on chronic hemodialysis presented with hematemesis. He had severe facial swelling, cervical plethora and peak airway pressures greater than 50. Emergent esophagogastroduodenoscopy demonstrated diffuse esophageal varices with no focal source of bleeding. Bronchoscopy was performed after frank blood was suctioned from the endotracheal tube, which revealed blood clots, diffuse airway hyperemia, and no focal source of bleeding. Computed tomography of chest and abdomen demonstrated total occlusion of the SVC with enlarged azygous and hemiazygous veins as well as extensive chest wall and abdominal venous collaterals. He did not have underlying liver pathology or portal hypertension. The patient underwent venoplasty and stenting of the SVC with restoration of SVC patency. His facial and cervical plethora resolved, and there was no further hemoptysis or hematemesis. DISCUSSION: Although SVC syndrome is classically described by malignancies that cause direct mass effect on the SVC, our patient is an example of a growing subset of SVC syndrome caused by catheter associated SVC stenosis. SVC obstruction forces blood to return to the heart via the azygous vein, hemiazygous vein, and mediastinal collaterals, resulting in the formation of downhill varices in the esophagus. (1,2) Although the mechanism for hemoptysis in SVC syndrome is not well described, ulceration or rupture of bronchial vein varices in patients with mitral stenosis (MS) has been used to explain hemoptysis in the absence of acute pulmonary edema or pulmonary infarction.(3) Injection studies in the autopsy specimens of patients with MS showed engorged bronchial vein varices from increased left atrial pressure and reversal of blood flow from the pulmonary circulation into the bronchial veins and into the right side of the heart via the azygos system.(3) In our patient, increased hydrostatic pressure from SVC occlusion and intrathoracic pressures from positive pressure ventilation likely led to microruptures in the bronchial veins causing hemoptysis. CONCLUSIONS: Catheter-associated SVC stenoses are becoming a more frequent cause of SVC syndrome. Chronic fluid build-up in the venous system can result in complications such as downhill esophageal and bronchial vein distension. Diagnosis should be considered when patients present with upper gastrointestinal bleeding or hemoptysis and the classic symptoms of SVC syndrome. Reference #1: Calderwood AH, Mishkin DS. Downhill esophageal varices caused by catheter-related thrombosis. Clin Gastroenterol Hepatol. 2008;6(1):e1. Reference #2: Felson, B. and Lessure, A.P. “Downhill” varices of the esophagus. Dis Chest. 1964; 46: 740–746 Reference #3: Schwartz R, Myerson RM, Lawrence T, Nichols HT. Mitral stenosis, massive pulmonary hemorrhage, and emergency valve replacement. N Engl J Med. 1966;275(14):755-8. DISCLOSURES: No relevant relationships by Meredith Greer, source=Web Response No relevant relationships by William Hunt, source=Web Response No relevant relationships by Jeeyon Rim, source=Admin input No relevant relationships by Manasi Tannu, source=Web Response