1. Circumferential venolysis and paraclavicular thoracic outlet decompression for “effort thrombosis” of the subclavian vein 
Robert W. Thompson, MD, Peter A. Schneider, MD, Nicolas A. Nelken, MD, Claes G. Skioldebrand, MD, Ronald J. Stoney, MD 
Journal of Vascular Surgery 
Volume 16, Issue 5, Pages (November 1992)
DOI: / (92)90227-Y
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

2. Fig. 1
Surgical technique for circumferential subclavian venolysis and paraclavicular thoracic outlet decompression. A, Paraclavicular approach uses both supraclavicular and medical infraclavicular incisions to gain access to entire costoclavicular space and first rib, with clavicle intact. B, Through supraclavicular exposure, subclavian vein is found encased and compressed by dense scar. C, Circumferential dissection frees vein of extrinsic compression. D, After restoration of subclavian vein patency, it is still susceptible to compressive forces between scalene musculature and first rib. E, Complete scalenectomy is combined with first rib resection; first rib is excised as far medially as costosternal junction through access obtained with infraclavicular incision. F, View of operative field at completion of procedure; brachial plexus neurolysis is added for any evidence of neurogenic thoracic outlet syndrome.
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

3. Fig. 2
Venography in case 2. Right arm venous obstruction became symptomatic 6 months after transaxillary first rib resection. A, Preoperative study shows calcified medial first rib remnant (closed arrows), posterolateral first rib remnant (open arrows), and subclavian vein obstruction within costoclavicular space. B, Postoperative study shows restoration of subclavian vein patency.
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

4. Fig. 3
A–B. Clinical findings in case 4, with positional postthrombotic subclavian vein compression. Clinical appearance of right arm before (A) and after (B) operation.
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

5. Fig. 3
C–D. Preoperative positional venography shows subclavian vein patency with arm at rest (C) and high-grade stenosis at level of first rib with arm elevated 90 degrees (D).
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

6. Fig. 3
E–F. Preoperative venography shows complete occlusion with arm fully elevated, enhancing collateral vessel pathways (E). Postoperative venography shows subclavian vein patency with arm fully elevated (F).
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions

7. Fig. 4
Preoperative venography in case 5. Right arm had been affected by previous “effort” thrombosis of subclavian vein. A, Symptomatic right arm has complete subclavian vein occlusion at level of first rib, with numerous draining collateral vessels. B, Asymptomatic left arm has positionally enhanced, high-grade stenosis of subclavian vein at same anatomic location.
Journal of Vascular Surgery  , DOI: ( / (92)90227-Y)
Copyright © 1992 Society for Vascular Surgery and the North American Chapter, International Society for Cardiovascular Surgery Terms and Conditions