Technique of supraclavicular decompression for neurogenic thoracic outlet syndrome  Richard J. Sanders, MD, Stephen J. Annest, MD  Journal of Vascular Surgery  Volume 61, Issue 3, Pages 821-825 (March 2015) DOI: 10.1016/j.jvs.2014.11.047 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Patient is placed on the operating table in the beach chair position, with hands crossed over the abdomen, and a towel under the shoulder on the side to be operated on. Journal of Vascular Surgery 2015 61, 821-825DOI: (10.1016/j.jvs.2014.11.047) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Incision, 1 to 2 cm above the clavicle and 5 to 7 cm long. B, The upper skin flap is dissected just superficial to sternocleidomastoid muscle (SCM) and below the fat underneath the platysma. The flap is elevated as far as possible. C, Vertical division of scalene fat pad. D, Exposure of the C5 and C5 branch of the phrenic nerve (also called the accessory phrenic nerve). The lateral edge of the anterior scalene muscle (ASM) may be seen. The middle scalene muscle (MSM) is lateral to C5. E, C5, C6, C7, C8, and T1 are dissected free. The subclavian artery (SA) is exposed and surrounded with a vessel loop. F, The Harmonic scalpel is used to divide the ASM near the first rib insertion. G, The freed lower end of the ASM is grasped with a clamp, elevated, and the proximal end of the ASM is divided above C5 with the Harmonic scalpel. If space is too tight, bipolar cautery and scissors are used. H, The MSM is divided with the Harmonic scalpel after the C5 and C6 branches of long thoracic nerve (LCN) are identified. I, The neck of the first rib is divided with the Raney Rongeur. If there is enough room, the Schumacher rib cutter may be used (Fig 3, B). J, One cm of the first rib is excised and a finger is used to free pleura from the underside of the rib. The rib is elevated with the right angle end of a periosteal elevator, which allows a finger to get behind the rib. K, The anterior end of the rib is divided by an infraclavicular rib cutter (by Pilling, Teleflex Medical Triangle Park, NC). The SA is retracted upward, and two retractor blades are removed to permit the rib cutter to reach the rib. The anterior rib stump is smoothed with Raney Rongeur to prevent the tip of the rib from injuring the SA lying above it. L, The divided rib section is extracted from behind the plexus and the SA with a Kocher clamp. Journal of Vascular Surgery 2015 61, 821-825DOI: (10.1016/j.jvs.2014.11.047) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Incision, 1 to 2 cm above the clavicle and 5 to 7 cm long. B, The upper skin flap is dissected just superficial to sternocleidomastoid muscle (SCM) and below the fat underneath the platysma. The flap is elevated as far as possible. C, Vertical division of scalene fat pad. D, Exposure of the C5 and C5 branch of the phrenic nerve (also called the accessory phrenic nerve). The lateral edge of the anterior scalene muscle (ASM) may be seen. The middle scalene muscle (MSM) is lateral to C5. E, C5, C6, C7, C8, and T1 are dissected free. The subclavian artery (SA) is exposed and surrounded with a vessel loop. F, The Harmonic scalpel is used to divide the ASM near the first rib insertion. G, The freed lower end of the ASM is grasped with a clamp, elevated, and the proximal end of the ASM is divided above C5 with the Harmonic scalpel. If space is too tight, bipolar cautery and scissors are used. H, The MSM is divided with the Harmonic scalpel after the C5 and C6 branches of long thoracic nerve (LCN) are identified. I, The neck of the first rib is divided with the Raney Rongeur. If there is enough room, the Schumacher rib cutter may be used (Fig 3, B). J, One cm of the first rib is excised and a finger is used to free pleura from the underside of the rib. The rib is elevated with the right angle end of a periosteal elevator, which allows a finger to get behind the rib. K, The anterior end of the rib is divided by an infraclavicular rib cutter (by Pilling, Teleflex Medical Triangle Park, NC). The SA is retracted upward, and two retractor blades are removed to permit the rib cutter to reach the rib. The anterior rib stump is smoothed with Raney Rongeur to prevent the tip of the rib from injuring the SA lying above it. L, The divided rib section is extracted from behind the plexus and the SA with a Kocher clamp. Journal of Vascular Surgery 2015 61, 821-825DOI: (10.1016/j.jvs.2014.11.047) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Special instruments: (A) Mini-Omni retractor, table mounted. B (left to right), Harmonic scalpel, periosteal elevator, Schumacher bone cutter, infraclavicular bone cutter (Pilling; Teleflex Medical, Triangle Park, NC), and Raney Rongeur. Journal of Vascular Surgery 2015 61, 821-825DOI: (10.1016/j.jvs.2014.11.047) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 Chest X-ray image. A, Straight first ribs usually need excision. B, Curved first ribs probably do not require an excision. Reprinted with permission from Sanders RJ. Thoracic outlet syndrome: general considerations. In: Cronenwet JL, Johnston KW, editors. Rutherford's vascular surgery. 7th edition. Philadelphia, PA: Saunders; 2010. p. 1865-77. Journal of Vascular Surgery 2015 61, 821-825DOI: (10.1016/j.jvs.2014.11.047) Copyright © 2015 Society for Vascular Surgery Terms and Conditions