Citation: Journal of Vascular Surgery. 2020, 72(3), 790-8. Epub 2020 Jun 1
Author: Ohman JW, Annest SJ, Azizzadeh A, Burt BM, Caputo FJ, Chan C, Donahue DM, Freischlag JA, Gelabert HA, Humphries MD, Illig KA, Lee JT, Lum YW, Meyer RD, Pearl GJ, Ransom EF, Sanders RJ, Teijink JAW, Vaccaro PS, van Sambeek MRHM, Vemuri C, Thompson RW
Abstract: The global SARS-CoV-2/COVID-19 pandemic has required a reduction in non-emergency 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 3 defined types of TOS (neurogenic, venous, and arterial) and 3 phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources): (1) In-person evaluation and treatment for neurogenic TOS (interventional or surgical) is generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. (2) Venous TOS presenting with acute upper extremity deep vein 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. (3) 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 vein thrombosis; endovascular treatment; hospital resources; neurogenic; subclavian artery; subclavian vein; surgical treatment; teleconference; telemedicine; thromboembolism; triage; upper extremity.
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