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Cranial Vena Cava Syndrome Isn’t that the thing with heartworm disease???

Cranial Vena Cava Syndrome Isn’t that the thing with heartworm disease???. Trisha Oura, DVM March 1, 2010. Acc # 125214 (Motown). - 10 yo FS GSD - 3 week history of submandibular swelling now cervical and forelimb Coughing (especially at night), decreased appetite

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Cranial Vena Cava Syndrome Isn’t that the thing with heartworm disease???

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  1. Cranial Vena Cava SyndromeIsn’t that the thing with heartworm disease??? Trisha Oura, DVM March 1, 2010

  2. Acc # 125214 (Motown) • - 10 yo FS GSD • - 3 week history of submandibular swelling now cervical and forelimb • Coughing (especially at night), decreased appetite • Thoracic radiographs: pulmonary nodules • Abdominal ultrasound: cavitated splenic mass • CT:

  3. Bilobed, partially mineralized thyroid mass with esophageal compression • Vascular filling defects • left external jugular v, cranial vena cava • Pulmonary nodules • Cervical, thoracic lymphomegaly • Marked subcutaneous edema Cranial vena cava syndrome

  4. Cranial Vena Cava Syndrome • Uncommonly reported in veterinary literature • Bronchogenic carcinoma, LSA = 95% human cases • Pathophysiology: • Compression, invasion, intraluminal obstruction • Elevated hydrostatic pressure • Interstitial fluid leakage, overwhelms lymphatics

  5. CrVCS • Clinical signs: • Subcutaneous, pitting edema (head, neck, forelimbs), jugular/scleral/conjunctival venous distension ** usually symmetrical ** • Pleural effusion (chylous), rarely pericardial • Gradual or acute onset • Collateral circulation within 1 week

  6. CrVCS • Reported causes: • Thymoma (canine) • Mediastinal lymphoma • Fungal (blastomycosis) • Carcinoma • Aortic body tumors • Pacemaker and IV catheter associated thrombi

  7. CrVCS • Ddx: • Angioedema • Snake bite • Trauma • Salivary mucocele • Abscess/cellulitis • Hypoalbuminemia/vasculitis (usually generalized) • Diagnostics: Image! Image! Image! and aspirate…

  8. CrVCS • Treatment • Remove the underlying cause if possible • Surgery/chemotherapy/radiation for neoplasia • Remove catheters/lead wires • Thrombolytics • Interventional • Balloon/Stent • Prognosis: • Guarded to poor • Collateral circulation • Invasive tumors not amenable to therapy

  9. Pacemaker induced caval thrombus and stricture formationCunningham SM, et al. JAVMA 2009;235:1467-1473. • 2 cases with pacemakers placed years ago • 1 = acute clinical signs (dyspnea, swelling) • Large volume recurrent PF • CrVC thrombus/stricture on CT • Thrombolytics, anticoagulants, balloon venoplasty • 1 = chronic, ‘incidental’ • Found at pacemaker replacement • Collateral vessels seen on angiography • Balloon venoplasty

  10. Pacemaker induced caval thrombus and stricture formation Case 1: acute onset clinical signs Case 2: asymptomatic, incidental Good outcome > 6 months!

  11. Not to be confused with….Heartworm Caval Syndrome • Life-threatening • Thought to occur with large numbers of worms maturing in short time • Severe pulmonary hypertension,  CO • Adults migrate from MPA to RA, RV +/- vena cava • Mechanical disruption of TV, physical obstruction • Trauma to RBC, hemolysis, anemia, icterus • Experimentally = as low as 12 worms (mean = 40)

  12. References • Bove CM, et al. Outcome of minimally invasive surgical treatment of heartworm caval syndrome in dogs: 42 cases (1999-2007). J Am Vet Med Assoc 2010;236:187-192. • Cunningham SM, MK Ames, JE Rush, EA Rozanski. Successful treatment of pacemaker-induced stricture and thrombosis of the cranial vena cava in two dogs by use of anticoagulants and balloon venoplasty. J Am Vet Med Assoc 2009;235:1467-1473. • Ncastro A, E Cote. Cranial vena cava syndrome. CompendContinEducPract Vet 2002;24:701-710.

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