Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19

J Vasc Surg. 2020 Sep;72(3):790-798. doi: 10.1016/j.jvs.2020.05.048. Epub 2020 Jun 1.


The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

Keywords: Axillary artery; Brachial plexus; Consensus; Coronavirus; Deep venous thrombosis; Endovascular treatment; Hospital resources; Neurogenic; Subclavian artery; Subclavian vein; Surgical treatment; Teleconference; Telemedicine; Thromboembolism; Triage; Upper extremity.

MeSH terms

  • Betacoronavirus / pathogenicity*
  • COVID-19
  • Consensus
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / prevention & control*
  • Coronavirus Infections / transmission
  • Coronavirus Infections / virology
  • Decompression, Surgical / standards
  • Elective Surgical Procedures / methods
  • Elective Surgical Procedures / standards
  • Emergency Treatment / methods
  • Emergency Treatment / standards
  • Humans
  • Infection Control / standards
  • Interdisciplinary Communication
  • Limb Salvage / methods
  • Limb Salvage / standards
  • Pandemics / prevention & control*
  • Patient Selection
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / prevention & control*
  • Pneumonia, Viral / transmission
  • Pneumonia, Viral / virology
  • Practice Guidelines as Topic*
  • SARS-CoV-2
  • Telemedicine / standards
  • Thoracic Outlet Syndrome / diagnosis*
  • Thoracic Outlet Syndrome / etiology
  • Thoracic Outlet Syndrome / therapy
  • Thrombolytic Therapy / methods
  • Thrombolytic Therapy / standards
  • Time-to-Treatment / standards
  • Triage / standards*