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A 75-year-old man with a substantial smoking history and stage IV non–small-cell carcinoma of the lung presented with progressive symptoms of cough, hoarseness, and swelling of the face and arms. On examination, he appeared plethoric, with a ruddy complexion, suffusion, pitting edema of the face and upper torso, and prominent spidery telangiectasia on his face and chest (Panel A). The jugular veins were nonpulsatile and distended. Contrast-enhanced computed tomographic imaging of the chest revealed a markedly compressed superior vena cava (SVC). An invasive venogram confirmed this finding and demonstrated severe compression of both the right and left subclavian veins (RSV and LSV), a thrombus in the left subclavian vein (Panel B), and multiple venous collaterals (Panel B, arrowheads). After local infusion of tissue plasminogen activator to reduce the burden of the thrombus, a polytetrafluoroethylene-covered stent was placed, extending from the left subclavian vein into the superior vena cava, intentionally occluding the vestige of the right subclavian vein. The patient felt better within a day, had noticeably less facial swelling at 7 days, and was back to baseline at 27 days (Panel C); the venographic result is also shown (Panel D). He subsequently received further chemotherapy and, 14 months after the procedure, remains free of symptoms resulting from the obstruction of the superior vena cava.
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