Surgical Approaches for Thoracic Outlet Syndrome: A Review of the Literature

Thoracic outlet syndrome (TOS) is caused by entrapment of the neurovascular bundle in the interscalene, costoclavicular, or subpectoral minor space. Compression in the interscalene or costoclavicular space with the first rib and scalene muscle leads to vascular and neurogenic TOS, whereas compression in the subpectoral minor space leads to pectoralis minor syndrome. Various surgical approaches exist for the treatment of TOS. The introduction and development of surgical approaches have minimized surgical invasiveness and complications. The reported approaches include transaxillary, supraclavicular, infraclavicular, posterior, combined transaxillary and supraclavicular, combined supraclavicular and infraclavicular (paraclavicular), endoscopic-assisted transaxillary, and video-assisted thoracoscopic approaches. In this review, we summarize the reported surgical approaches for TOS treatment, in terms of the history of the approach, surgical procedure, advantages and disadvantages, clinical outcomes, and complications. An adequate excision of compression structures, including the first rib and scalene muscles, provides satisfactory outcomes regardless of the approach selected, whereas an inadequate release of compression structures leads to failed or recurrent outcomes. Reducing the risk of complications is the most important aspect of TOS management. Surgery should be performed safely, with sufficient resection of compression structures. Additionally, the approach should be selected based on the surgeon's skill, surgeon's preferences, surgical invasiveness, cosmetic appearance, and the presence of special equipment, as well as other advantages and disadvantages of each approach.