Transaxillary first rib resection remains the traditional operative approach to thoracic outlet decompression. In well-selected patients, it is still successfully employed by many experienced surgeons. With proper measures to protect the neurovascular structures and to accomplish adequate resection of the anterior scalene muscle, long-term relief of neurogenic symptoms is clearly achievable by this approach. It is important to recognize, however, that most vascular trainees currently obtain little experience with transaxillary first rib resection or other procedures for TOS. They must therefore be knowledgable of the potential hazards and intrinsic limitations of this technique for neurogenic TOS, and that it is generally not applicable to venous or arterial syndromes. Indeed, recent reports indicate that surgeons who frequently treat thoracic outlet problems have increasingly favored the versatility and familiarity of supraclavicular exploration for virtually all forms of TOS. This approach will be discussed in detail in the second article of this series.