The thoracic outlet syndrome (TOS) encompasses a variety of conditions caused by compression of the neurovascular structures passing between the clavicle, the scalene muscles, and the first rib (Figure 1). When a patient’s symptoms warrant operative therapy, transaxillary first rib resection can be performed successfully in most cases. Varying therapeutic approaches for the different manifestations of TOS exist (Table 1).

Transaxillary interventions for TOS are not appropriate for the following: (1) fixed vascular pathology that requires a direct vessel repair, (2) a broad-based cervical rib, (3) pure upper plexus symptoms with tenderness over the scalene muscles and a history of trauma, and (4) a prior shoulder operation. In each of these situations, a supraclavicular incision provides better and safer exposure for either first or cervical rib resection. The medial clavicle might need to be removed for better exposure of the vessels in some patients. In the case of a patient with a prior shoulder procedure, the extreme abduction of the shoulder during the transaxillary rib resection can reinjure the shoulder and should be avoided if possible.

The role for rib resection in the acute venous syndrome is not always clear. In most instances, catheter-directed thrombolysis is recommended when a patient presents with an acute effort thrombosis of the axillosubclavian vein. If patency is achieved and there is a persistent stenosis, one can make an argument for immediate transaxillary rib resection. If the stenosis is caused by an extrinsic lesion, the rib resection should solve the problem. On the other hand, if the stenosis is intrinsic, endovascular angioplasty with stenting is pursued. Transaxillary resection of the first rib should be performed in patients with chronic venous TOS when the collateral veins are compressed by shoulder abduction. This diagnosis can be confirmed with a phlebogram. It is crucial in these patients to remove the entire medial portion of the rib. If these patients require direct venous reconstruction, it is best not to remove the first rib but to decompress the outlet from above in order to have better access to the vessels.

Transaxillary first rib resection is not often used for arterial involvement. Because these cases are almost always a result of a large cervical rib, an anterior approach is preferred. The transaxillary approach should be used only in those rare instances of arterial compression in the absence of a cervical rib and fixed arterial pathology.

Proper patient selection is an important determinant of results after transaxillary rib resection for neurologic symptoms (Table 2). The decision to operate should be made only after a complete neurologic evaluation has excluded any other entity that could cause similar symptoms.

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