Point/counterpoint: Paraclavicular decompression is the best approach for venous thoracic outlet syndrome

In this point/counterpoint chapter, we present the view that paraclavicular decompression is the best approach for the surgical treatment of venous thoracic outlet syndrome (TOS). This is based on considering the limitations and deficiencies of the transaxillary and infraclavicular approaches, as well as the distinct advantages of the paraclavicular approach. This approach thereby combines the benefits of both supraclavicular and infraclavicular exposures, represents the only approach by which to routinely obtain complete resection of the entire first rib, and offers the potential for direct reconstruction of the subclavian vein when needed, in a single operation. The results of treatment are excellent with current evidence favoring the paraclavicular approach over transaxillary and infraclavicular approaches. We conclude that in the hands of surgeons with experience and expertise, operative procedures based on the paraclavicular approach offer the most comprehensive, versatile, safe, and evidence-based approach to the treatment of venous TOS, as well as a predictably higher rate of success than other strategies to address this condition.