Arterial thoracic outlet syndrome caused by a cervical rib: a combined thoracoscopic and supraclavicular approach for ‘<i>en bloc’</i>-resection

A cervical rib is the cause of ∼5% of thoracic outlet syndromes (TOS). We report the case of a patient with arterial TOS due to the presence of a cervical rib, managed by combined thoracoscopic and supraclavicular approach. An 18-year-old female patient presented with symptoms of arterial TOS. Magnetic resonance imaging and computed tomography angiography scans showed a tortuous subclavian artery due to a fused cervical and 1st rib. Three-port thoracoscopy was performed, which allowed to mobilize the ventral part of the 1st rib. Supraclavicular access allowed mobilization as well as central division of the ribs. After removal of the ribs, the subclavian artery presented a normal calibre and aspect. In recent years, there has been a trend towards minimally invasive approach to TOS, either by thoracoscopy or by robotic-assisted surgery. The advantages of this approach are the 'enbloc'-resection of both ribs and the possibility to evaluate the subclavian artery during the same procedure and perform repair if necessary.