Unsuspected Superior Vena Caval Obstruction Detected by Angiocardiography

Angiocardiography is rapidly becoming a routine method for adequate evaluation of upper mediastinal lesions and has increased significantly the accuracy of diagnosis of mediastinal masses. We report here a case of superior vena caval obstruction which was totally unsuspected clinically. This case takes on added interest since our examinations established the fact that the obstruction to the superior vena cava extended to below the opening of the azygos vein into the superior vena cava, and also that there was obstruction of the left innominate and right subclavian veins. B. S., a 76-year-old Negro female, entered the hospital Nov. 18, 1951, because of a superior mediastinal mass. She had become ill in December 1950, at which time anorexia occurred and she began to lose weight. In July 1951, she began to experience pain, varying in location from the upper right and left parasternal region of the chest to the left side of the neck. This was thought to be precipitated by eating but not by walking. Roentgen examination of the chest on Oct. 10, 1951, by a private physician, revealed a mass in the upper right mediastinum. An admission chest film confirmed this finding (Fig. 1). Physical examination revealed evidence of weight loss. A slight bulge was present on the right side of the sternum, where dullness and tenderness were elicited. There were no pulsations. The point of maximum impulse of the heart was in the sixth intercostal space, just to the left of the mid-clavicular line. The rhythm was regular, with infrequent premature beats; A2 was louder than P2. The remainder of the physical examination was essentially negative. Especially striking was the absence of venous distention in the arms and chest. The temperature was normal, pulse 108, respirations 20. The blood pressure was 160 systolic and 80 diastolic. Venous pressure was 210 mm. H2O in the right arm and 260 mm. H2O in the left arm. The urine had a specific gravity of 1,012, and was negative for albumin and glucose. The sediment contained a few pus cells, epithelial cells, and bacteria. Examination of the blood revealed: hemoglobin, 8.6 gm.; red cells, 2,830,000; hematocrit, 29 per cent; white cells, 5,450, with a normal differential count. The total protein was 8.45 gm. per cent; albumin 3.47 gm. per cent; globulin 4.98 gm. per cent. The non-protein nitrogen was 22 mg. per cent, the fasting blood glucose 77 mg. per cent, and the chlorides 101 mEq.∕L. A blood Wassermann test was negative. The electrocardiogram was suggestive of myocardial damage. An esophagogram and a gastrointestinal series were normal. Fluoroscopic examination of the chest revealed a non-pulsating mass in the right anterior superior mediastinum. The heart was enlarged slightly in the region of the left ventricle.