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Thoracic Outlet Syndrome



Related narrative: Thoracic Outlet Syndrome, Thoracic Outlet Syndrome (Cervical Ribs)

Neurovascular compression syndromes in the superior thoracic aperture (thoracic outlet) may be due to first rib anomalies or abnormal muscle insertions in the interscalene triangle (between anterior scalene, middle scalene and first rib: see neck anatomy), compression in the costoclavicular triangle, or compression in the subcoracoid space. Hypertrophy of the anterior scalene or pectoral muscles, cervical rib, myofascial bands, scoliosis, and clavicular fracture malunion are among the etiologies.

There are three types of thoracic outlet compression syndromes, involving brachial plexus, subclavian artery, and subclavian vein. Neural compression is by far the most common (97%), and the majority of these will experience relief with nonoperative therapy. Vascular compromise, and refractory nerve compression are best treated by first rib resection, relieving anatomic narrowing in all three spaces cited above. The two currently favored approaches to first rib resection are supraclavicular and transaxillary. The supraclavicular approach provides good vascular exposure if reconstruction is necessary. The transaxillary approach may be difficult in muscular individuals.

Some (RJV) have begun using a combination supraclavicular and infraclavicular incision for venous thoracic outlet syndrome to fully relieve compression by the subclavius muscle and to resect the most anterior portion of the first rib. This is especially beneficial in muscular individuals.


Wind, GG, Valentine, RJ, Anatomic Exposures in Vascular Surgery, WIlliams & Wilkins, Baltimore, 1991, 105-136.

This page was last modified on 8-Oct-2001.