Neurovascular compression at the thoracic outlet results from one or several local anatomic abnormalities, all involving the first rib to some extent. The pathologic processes produced involve syndromes usually affecting the ulnar nerve, the subclavian artery, or the subclavian vein. The majority of these cases should be managed in a nonoperative fashion and surgical treatment reserved for patients who are unresponsive to these measures. Initial conservative nonoperative treatment with physiotherapy and patient education produces satisfactory results in 70 per cent of the patients. Operative intervention, when necessary, results in satisfactory results in 90 per cent of the cases and requires first rib resection in conjunction with repair of all other attendant mechanisms. The anterior operative approach is strongly recommended whenever vascular repair is contemplated.