Evidence - Thoracic outlet syndrome (TOS) - Left transaxillary first rib resection (TFRR) - Vascular surgery

  1. Literature summary

    Meta-analyses and systematic reviews

    There is one Cochrane review from 2014 on the treatment of TOS.[1] There are also three randomized trials mainly focusing on the lack of accepted diagnostic criteria in TOS. Besides, only two of the trials had a follow-up of at least 6 months. The review found weak evidence that transaxillary resection of the first rib reduces symptoms more than supraclavicular neuroplasty.

    There is moderate evidence that electromyographically guided botulinum toxin injections into the anterior and middle scalene muscles are not more effective than placebo injection with saline.[2]

    A meta-analysis addressed the issue of whether in acute Paget-von-Schroetter syndrome (VTOS) subsequent thoracic outlet decompression was indicated on top of thrombolysis.[3] Compared were the following: thrombolysis + subsequent resection of the first rib (448 patients) versus thrombolysis + first rib resection + balloon venoplasty (68 patients) versus thrombolysis alone (168 patients). Symptom relief and patency rate were significantly better when the first rib was also resected.

    Studies and registry data

    Between 2005 and 2014, the NSQIP database ("American College of Surgeons National Surgical Quality Improvement Program") identified a total of 1431 patients with resection of the first rib or cervical rib in NTOS (83%), VTOS (12%), and ATOS (3%).[4] The following complications were reported: Nerve injury in 0.3% of patients, bleeding complication requiring transfusion, and deep vein thrombosis in 1.4% each, and wound infection in 1% of patients. The rate of reoperations was given as 6.0%, and the rate of readmission as 5.2%. An increased complication rate was found in patients with higher ASA classification, surgery for non-neurogenic symptoms, and long operating times. Attention was drawn to the low rate of brachial plexus injuries. The vast majority of patients (n = 1286) were treated by vascular surgeons.

    Another analysis of the NSQIP database from 2017 covers data between 2005 and 2013 on 1180 resections of the first rib or cervical rib.[5] The indication was NTOS in 1007 cases (85.3%), VTOS in 141 cases (12%), and ATOS in 32 cases (2.7%). ATOS patients were significantly older and also had longer operating times and length of stay in the hospital. The complication rate was consistent with the registry data above.

    The 10-year findings from the Johns Hopkins Center for resection of the first rib in all three types of TOS were published in 2015.[6] A total of 538 patients were treated (594 were first rib resections, 9.4% bilateral procedures), 8.8% of patients had an additional cervical rib. Standard surgical access was via the transaxillary approach. Complications identified included: intraoperative pneumothorax in 23%, wound infections in 1.3% of cases, 6 hematomas (2 patients with hemothorax), and two venous injuries. There were no reports of lesions to the brachial plexus. The mean length of stay was only 1 day. At follow-up, the percentage of patients with improved or completely resolved symptoms and patent subclavian vessels accounted for 93% and 96%, respectively. The outcomes attest to the benefit of managing TOS patients in specialized centers.

    Another expert center in St. Louis reported on 189 patients with NTOS.[7] Standard access was via the supraclavicular approach with complete resection of the anterior and middle scalene muscle, neurolysis of the brachial plexus, and resection of the first rib. Interestingly enough, this patient group also included 35 adolescents with a mean age of 17 years. The complication rate was 4.2% (1 postoperative secondary bleeding, 2 wound infections, and 5 lymphatic fistulas). Compared with older adults (mean age 40 years), the adolescent patients had a shorter medical history, higher rates of participation in sports, and recurrent exercise injury. Follow-up at 6 months revealed significant symptom relief in adolescents compared with adults. It remained unclear whether the better outcome in adolescents was due to their shorter medical history or to age per se.


  2. Ongoing trials on this topic

  3. Literature on this topic

    1. Povlsen B, Hansson T, Povlsen SD (2014) Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev 11:CD007218

    2. Finlayson HC, O’Connor RJ, Brasher PM, Travlos A (2011) Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain 152:2023–2028

    3. Lugo J, Tanious A, Armstrong P, Back M, Johnson B, Shames M, Moudgill N, Nelson P, Illig KA (2015) Acute Paget-Schroetter syndrome: does the first rib routinely need to be removed after thrombolysis? Ann Vasc Surg 29:1073–1077

    4. Rinehardt EK, Scarborough JE, Bennett KM (2017) Current practice of thoracic outlet decompression surgery in the United States. J Vasc Surg 66:858–865

    5. Nejim B, Alshaikh HN, Arhuidese I, Obeid T, Lum YW, Canner J, Locham SS, Malas M (2017) Perioperative outcomes of thoracic outlet syndrome surgical repair in a nationally validated database. Angiology 68:502–507

    6. Orlando MS, Likes KC, Mirza S, Cao Y, Cohen A, Lum YW, Reifsnyder T, Freischlag JA (2015) A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. J Am Coll Surg 220:934–939

    7. Caputo FJ, Wittenberg AM, Vemuri C, Driskill MR, Earley JA, Rastogi R, Emery VB, Thompson RW (2013) Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations. J Vasc Surg 57:149–157


Archie M, Rigberg D. Vascular TOS-Creating a Protocol and Sticking to It. Diagnostics (Basel). 2017

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