15-year thrombus-driven superior vena cava syndrome associated with sports.

A 42-year-old man with a history of superior vena cava syndrome (SVCS) for 15 years had symptoms that gradually progressed. In 2006, after high-intensity arm exercises with a power twister, he developed symptoms of after-activity neck swelling and matutinal facial swelling. Computed tomography venography (CTV) performed six weeks later showed right jugular vein, bilateral brachiocephalic vein and right subclavian vein thrombosis. After anticoagulant and catheter-directed thrombolytic therapy, venography still revealed occlusion of the bilateral subclavian vein and superior vena cava. His-symptoms had not significantly progressed until 2015. Hoarseness, neck thickening, dyspnea on exertion and occasionally nightly suffocation had begun to appear in the previous six years. He had no family history of venous thrombosis and no basic diseases such as hypertension. Physical examination showed a few visible superficial veins of the anterior chest wall. All of his blood test results, including the coagulation markers, were normal. Venography through the catheter (Fig. 1) showed occlusion of the superior vena cava and bilateral subclavian vein along with expanded collateral circulation. The lateral thoracic vein (white empty arrow) developed in the reverse direction. Blood flowed retrogradely through the enlarged azygos vein (black arrow), hemiazygos vein (black empty arrow) and ascending lumbar vein to the left renal vein (asterisk) and inferior vena cava and from there into the right atrium. CTV and three-dimensional reconstruction (Fig. 2) also showed expanded lateral thoracic vein (white empty arrow), hemiazygos vein and internal thoracic veins (white arrow). Blood via the prominent collateral circulation of the thoracoabdominal vein, superficial epigastric vein and inferior epigastric vein (red arrow) enters the iliofemoral vein. However, CTV demonstrated no obvious evidence of compression in the thoracic outlet. Fig. 2 View Large Image Figure Viewer Download Hi-res image