Venous TOS is distinct from other forms of TOS with respect to pathophysiology, clinical presentation, and functional consequences for the patient. Optimal management of axillary-subclavian vein compression thereby requires different considerations and approaches from those applicable to either neurogenic or arterial TOS. The purpose of this chapter is to describe a comprehensive strategy to the surgical treatment of venous TOS based on paraclavicular thoracic outlet decompression. This approach combines the advantages of supraclavicular exposure with an infraclavicular exposure that permits complete resection of the medial first rib, as well as wide exposure of the subclavian vein to permit direct vascular reconstruction in the same setting. Use of this approach allows definitive surgical treatment to be offered to all patients with symptomatic venous TOS or recent effort thrombosis, regardless of the interval between initial diagnosis and referral, previous treatment, or adverse findings on contrast venography, with excellent early and long-term outcomes. This has led us to conclude that operative procedures based on paraclavicular exposure provide the most versatile, comprehensive, and safe approach to the treatment of venous TOS.