Hypotensive patient with superior vena cava obstruction diagnosed using resuscitative transesophageal echocardiography

Background: Superior vena cava syndrome (SVCS) is a malignancy-related emergency. It is caused by obstruction of blood flow in the superior vena cava (SVC) secondary to intraluminal thrombosis, external compression, or direct invasion of tumor. Case summary: A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respira-tory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief. Discussion: This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alter-native ED imaging modality in the management of SVCS. Learning points: center dot Superior vena cava syndrome (SVCS) is a life-threatening emergency that should be considered in a hypoten-sive patient with suspected mediastinal malignancy. center dot Point-of-care ultrasound (POCUS) can be performed at the bedside during resuscitation to assess the cause of shock in a patient with undifferentiated hypotension. center dot Transesophageal echocardiography (TEE) is a valuable tool for evaluating the superior vena cava in an intubated patient when transthoracic echocardiography (TTE) findings are inconclusive due to poor image acquisition. center dot TEE can be used to confirm the diagnosis of SVC obstruction, demonstrate the mechanism causing the pathol-ogy and guide subsequent management.(c) 2023 Elsevier Inc. All rights reserved.