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VTOS Surgical Approaches

Infraclavicular incision

INFRACLAVICULAR

(below clavicle)

Paraclavicular incisions

PARACLAVICULAR

(above & below clavicle)

Transaxillary incision

TRANSAXILLARY

(through the armpit)

The three main surgical approaches used for VTOS are Infraclavicular, Paraclavicular and Transaxillary.  Which approach is used typically depends on surgeon preference, what they were trained in, and what they are most comfortable with.  Almost all TOS experts agree that the Supraclavicular approach is not sufficient for VTOS because they believe that it carries with it the inability to remove enough of the anterior portion of the first rib which results in incomplete and inadequate decompression of the vein which is a vital component of the surgery. From a safety standpoint, each of these approaches can be used safely as long as the surgeon is properly trained in both the surgery itself and the chosen approach.  TOS experts have stated pros and cons of each approach depending on which they prefer. Keep in mind that these experts have differing opinions about the pros and cons of each approach.  Below is a summary of the various pros and cons.

INFRACLAVICULAR

Pros

  • easy removal of the anterior portion of the first rib

  • avoid disruption of collateral veins that have formed

  • Ability to perform vein reconstruction

  • Ability to perform complete venolysis

  • Complete removal of subclavius muscle/tendon

  • Ability to perform intraoperative venogram

  • Ability to perform intraoperative balloon angioplasty

  • Avoid unnecessary interaction with the artery

  • Lower risk of brachial plexus nerve injury

Cons

  • Inability to remove entire first rib, particularly posterior rib

  • Inability to treat all patients with long occlusions

  • Inability to treat coexisting NTOS via complete posterior rib removal, scalene removal, & neurolysis

  • Inability to completely remove anterior & middle scalene muscles

  • Less cosmetically appealing scar

PARACLAVICULAR

Pros

  • Complete removal of the entire first rib

  • Ability to perform intraoperative venogram

  • Ability to perform vein reconstruction

  • Ability to perform complete venolysis

  • Complete removal of subclavius muscle/tendon

  • Ability to treat coexisting NTOS

  • Complete removal of both anterior & middle scalene muscles

  • Complete neurolysis of all 5 brachial plexus nerve roots

  • Ease of management of any intraoperative bleeding complications (although rare)

  • Ability to treat all VTOS patients no matter vein occlusion status

Cons

  • Higher incidence of phrenic nerve injury

  • Higher incidence of thoracic duct lymph leak

  • More technically challenging

  • More manipulation of the nerves

  • Longer operating time

  • Longer hospital stay

  • Less cosmetically appealing scar

TRANSAXILLARY

Pros

  • Ability to remove the entire first rib

  • Ability to work beneath the brachial plexus nerves to prevent injury to the same

  • Ability to avoid disruption of collateral veins that have formed

  • Ability to treat coexisting NTOS

  • Lower incidence of phrenic nerve injury

  • Lower incidence of thoracic duct lymph leak

  • Shorter operating time

  • Shorter hospital stay

  • Cosmetically appealing scar

Cons

  • Inability to perform intraoperative venogram & angioplasty without patient repositioning

  • Inability to perform vein reconstruction

  • Inability to perform complete venolysis

  • Inability to completely remove subclavius muscle/tendon

  • Inability to completely remove anterior & middle scalene muscles (only about 25% of the muscles can be removed)

  • Only able to perform neurolysis on the lower 2-3 nerve roots

  • Not as easy to remove posterior portion of first rib

  • More difficult management of intraoperative bleeding complication (although rare)

  • Inability to treat those patients with residual stenosis who are not responsive to balloon angioplasty

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