Successful Return to Active Duty after First Rib Resection for Thoracic Outlet Syndrome

Published:August 23, 2019DOI:


      The optimal surgical approach and treatment algorithm for thoracic outlet syndrome (TOS) remain controversial. We sought to examine the outcomes of patients treated at a military medical treatment facility (MTF) for TOS.


      A retrospective review was performed on all patients who had a first rib resection (FRR) for TOS over a 9-year period at a single MTF. Patient demographics, perioperative details, and patient outcomes were examined. Active duty (AD) status and return to AD were reviewed.


      From 2008 to 2016, 33 FRRs were performed in 32 patients. Of these, 30 patients were on AD with a mean age of 27 years (range, 19–44). The 29 male and 4 female patients were treated for symptoms of venous (23), neurogenic (6), or arterial (4) TOS. The mean time from onset of symptoms was 11 months (range, 1 to 120). The FRR was performed via a transaxillary (13), supraclavicular (12), or paraclavicular (8) approach. Of 21 AD patients with venous TOS, 16 (76%) underwent preoperative thrombolysis. A postoperative venogram or ultrasound was performed in 20 patients, documenting vein patency in 18 (90%). Nine patients underwent subsequent venoplasty or stent placement. Most patients (15) were placed on anticoagulation for 1–6 months. Two AD patients had perioperative complications including a lymph leak and brachial plexus palsy. Twenty-four (89%) patients returned to AD status. One recruit never returned to AD after successful FRR, and two other patients did not return for medical reasons unrelated to the FRR.


      Despite a variety of surgical approaches and often delayed presentation, we identified a high percentage of postoperative vein patency and return to AD status in our population. The debate over surgical approach remains; however, a multimodal approach individualized to the patient's presentation and meticulous surgical technique led to successful outcomes in our healthy military population.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Melby S.J.
        • Vedantham S.
        • Narra V.R.
        • et al.
        Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).
        J Vasc Surg. 2008; 47: 809-821
        • Thompson R.W.
        • Dawkins C.
        • Vemuri C.
        • et al.
        Performance metrics in professional baseball pitchers before and after surgical treatment for neurogenic thoracic outlet syndrome.
        J Vasc Surg. 2017; 39: 216-227
        • Chandra V.
        • Little C.
        • Lee J.T.
        Thoracic outlet syndrome in high-performance athletes.
        J Vasc Surg. 2014; 60: 1012-1018
        • Weiss J.S.
        • Coletta J.M.
        • Hall L.D.
        • et al.
        Vascular thoracic outlet syndrome.
        Curr Treat Options Card Med. 2002; 4: 195-206
        • Guzzo J.L.
        • Chang K.
        • Demos J.
        • et al.
        Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenectomy for subacute and chronic subclavian vein thrombosis.
        J Vasc Surg. 2010; 52: 658-663
        • Chandra V.
        • Olcott C.
        • Lee J.T.
        Early results of a highly selective algorithm for surgery on patients with neurogenic thoracic outlet syndrome: a prospective analysis.
        J Vasc Surg. 2011; 54: 1698-1705
        • Lee W.A.
        • Hill B.B.
        • Harris E.J.
        • et al.
        Surgical intervention is not required for all patients with subclavian vein thrombosis.
        J Vasc Surg. 2000; 32: 57-67
        • Bamford R.F.
        • Holt P.J.
        • Hinchcliffe R.J.
        • et al.
        Modernizing the treatment of venous thoracic outlet syndrome.
        Vascular. 2012; 20: 138-144
        • de Leon R.A.
        • Chang D.C.
        • Hassoun H.T.
        • et al.
        Multiple treatment algorithms for successful outcomes in venous thoracic outlet syndrome.
        Surgery. 2009; 145: 501-507
        • Orlando M.S.
        • Likes K.C.
        • Lum Y.W.
        • et al.
        Utilization of venous duplex scanning and postoperative venography in patents with subclavian vein thrombosis.
        J Vasc Surg. 2015; 3: 173-177
        • Chang K.Z.
        • Likes K.C.
        • Demos J.
        • et al.
        Routine venography following transaxillary first rib resection and scalenectomy (FRRS) for chronic subclavian vein thrombosis ensures excellent outcomes and vein patency.
        Vasc Endovasc Surg. 2012; 46: 15-20
        • Shutze W.
        • Richardson B.
        • Shutze R.
        • et al.
        Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome.
        J Vasc Surg. 2017; 66: 1798-1805
        • Kreienberg P.B.
        • Chang B.B.
        • Darling C.
        • et al.
        Long-term results in patients treated with thrombolysis, thoracic inlet decompression, and subclavian vein stenting for Paget-Schroetter syndrome.
        J Vasc Surg. 2001; 33: S100-S105
        • Illig K.A.
        • Donahue D.
        • Duncan A.
        • et al.
        Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome: executive summary.
        J Vasc Surg. 2016; 64: 797-802