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. As mentioned previously, in cases of severe blanching or swelling, this is a priority (if lasting and severe) and should prompt an immediate consultation with a vascular surgeon. For historical reasons, vascular surgeons also have the most experience in decompressing the brachial plexus. Because of the factors outlined above (in “Causes”), the best approach, generally, is a direct one above the clavicle, rather than through the axilla, for two reasons. The axillary approach usually involves resection of the 1st rib. The remaining stump, produces reactive oxygen species for a long time, often causing further scarring around the area of the nerve trunks. In addition, the field of view obtained by the surgeon makes it difficult, if not impossible, to perform a neurolysis or complete resection of the scalenes, which is much more easily performed with the supraclavicular approach. Results are highly variable and, in my experience, depend greatly on the expertise and number of cases performed by the surgeon. Generally, individuals with obvious anatomical defects, such as extra ribs or serious fibrotically induced deformations, do the best. Overall, when operated on by competent hands, approximately 50% of the patients report that the surgery was worthwhile.