Controversies in VTOS: What Is the Best Approach to the First Rib in VTOS?

The critical consideration in planning treatment for patients with venous thoracic outlet syndrome (VTOS) is that the decompression must include excision of the antero-medial part of the first rib. This can be accomplished via the transaxillary approach, the paraclavicular, or the infraclavicular approach. We prefer the infraclavicular approach to decompress the thoracic outlet for symptomatic VTOS. The infraclavicular approach has many advantages including direct visualization of the subclavian vein, avoiding disruption of venous collaterals, lower risk of injury to the brachial plexus and the phrenic nerve, and venous reconstruction when necessary. The transaxillary approach can be useful in a patient who has a normal vein after thrombolysis and is concerned with cosmesis. While the paraclavicular approach allows good visualization of the thoracic outlet, it requires a more extensive dissection including exposure of the brachial plexus, phrenic nerve and subclavian artery. Many believe that there is benefit to decompressing the venous thoracic outlet in symptomatic patients who have a chronically occluded subclavian vein. Finally, when the patient with a chronically occluded vein requires surgical reconstruction of the subclavian vein, it can be performed via either infraclavicular or paraclavicular approaches.