Key Points

• The transaxillary approach for thoracic outlet syndrome (TOS) is indicated primarily for nerve compression and venous obstruction.
• This technique is not ideal for arterial reconstruction as proximal control of the subclavian artery is difficult from the axilla. Additionally, it may be associated with incomplete decompression of the thoracic outlet and recurrence of symptoms.
• The long-term results of any surgical approach for TOS are good in a carefully selected patient when the 1st rib is either completely removed, or when only a small portion of the head of the rib is preserved.
• This approach provides the best cosmetic result.

The transaxillary approach to TOS surgery is favored by some surgeons for patients with primary venous thoracic outlet syndrome (including Paget-Schroetter syndrome) as well as those who continue to have symptoms of neurogenic TOS after physical therapy. Advocates of this technique cite multiple advantages over the supraclavicular approach including increased safety (less retraction of the axillary-subclavian vessels and brachial plexus), superior cosmesis (scar is hidden in the axilla) and preservation of major muscle groups (leading to shorter post-operative recovery).

In our experience, one major short-coming of this technique is the limited access to neurovascular structures which contributes to incomplete decompression of the thoracic outlet and can lead to treatment failure in neurogenic TOS. In arterial TOS, this limited access does not allow for adequate vascular control if bypass or resection is required for arterial obstruction or aneurysm. An additional consideration is the depth of the required surgical wound which mandates higher quality lighting and maginification in the operating room.