The clinical presentation of thoracic outlet syndrome depends on which anatomic structure is compressed in the area of the thoracic outlet (eg, the axillary-subclavian artery, vein, brachial plexus, or the sympathetic nerves). The clinical syndrome may be isolated to one or a mixture of these compressed anatomic structures. Although there are multiple compressive forces, the first rib is the common denominator, and extirpation of this structure is the "gold" standard for therapy. The various syndromes are discussed in their clinical order of frequency. For severe nerve compression, whether upper or lower brachial plexus, the best surgical procedure is the transaxillary first rib resection, anterior scalenectomy, and neurovascular decompression. Axillary-subclavian vein occlusion (ie, Paget-Schroetter syndrome) is best treated with early diagnosis, intravenous thrombolysis of the clot, transaxillary first rib resection anterior scalenectomy, and resection of the costoclavicular ligament. Arterial compression, occlusion, or aneurysm may occur with or without peripheral emboli and require a supraclavicular approach with arterial ligation, endarterectomy, or bypass grafts from the supraclavicular subclavian to the infraclavicular brachial artery. Compression of the sympathetic nerves produces vasospasm, Raynaud's phenomenon, or Raynaud's disease, requiring dorsal sympathectomy as well as first rib extirpation occasionally. This may be performed through the transaxillary, supraclavicular posterior, or thoracoscopic approach. Recurrent thoracic outlet syndrome may involve any or all of the above anatomic syndromes. The surgical approach is best from the posterior, high thoracoplasty, muscle-splitting incision, performing neurolysis of the C7, C8, and T1 nerve roots and the brachial plexus as well as release of any vascular constriction.