Thoracic outlet syndrome (TOS) presents with a constellation of symptoms caused by compression of the brachial plexus, subclavian artery and/or subclavian vein. Venous TOS (vTOS) comprises a minority of overall TOS cases but often appears in young and athletic individuals. The clinical manifestations of arm swelling and pain can be debilitating and affect long-term quality of life. This rare condition is frequently underdiagnosed in primary care or emergency room settings. Standard management includes anticoagulation and catheter-directed thrombolysis followed by thoracic outlet decompression via first rib resection. While there is no consensus regarding the best surgical approach, the infraclavicular technique is potentially advantageous by direct exposure of the subclavian vein for venolysis and adequate medial decompression of the thoracic outlet. In this article, we discuss our technique for infraclavicular rib resection, as well as advantages and outcomes for this approach.

The infraclavicular approach for vTOS was described by Nelson1 and subsequently championed by Molina2 and Murphy.3 While the infraclavicular approach is not suitable for neurogenic TOS or neurolysis due to the posterior location of the brachial plexus, the infraclavicular approach is a favorable approach for isolated vTOS. The surgeon can resect the subclavius muscle, costoclavicular ligament, and the medial aspect of the first rib. In addition, the subclavian vein is well-visualized and venolysis can be performed. This incision can be combined with a supraclavicular incision if needed or extended medially with a mini-sternotomy for more proximal subclavian vein reconstruction.