First Rib Resection Is Always Needed After Thrombolysis

Venous thoracic outlet syndrome (VTOS) is caused by compression of the subclavian vein by the structures in the costoclavicular space, and it is prudent to remove the bony hindrance leading to its pathogenesis, most commonly by first rib resection (FRR). This relieves the compression, re-expands the costoclavicular space, prevents rethrombosis, and increases patency of subclavian vein recanalization. There is level one evidence that FRR in VTOS leads to more symptom relief and higher patency than those without it. The majority of patients who did not have FRR initially eventually underwent the procedure, with diminished efficacy. Furthermore, the risks of FRR is low, and data in nonoperative management for VTOS is comparatively smaller and worse. In the absence of further analysis and protocol for selecting patients for non-operative management that reliably yields excellent results, routine FRR should be the standard of care for VTOS.