IC Approach – Figure 4
The incision commences 2cm below the clavicle and extends medially to the sternal border. The two heads of the pectoralis major are identified and access between the clavicular and manubrial insertions. The advantages of the IC approach are principally a direct incision over the first rib in order to access the anteriorly located SV. Removal of this part of the first rib is crucial in the satisfactory treatment of SV thrombosis. This enables rigorous debulking of the costchondral junction and subclavius muscle resection from the origin at the superior aspect of the medial first rib. The intercostal muscles can be divided from the lateral rounded aspect of the first rib and medially the dissection can proceed posteriorly to divide the insertion of the scalenus anterior muscle. This incision should only be used when the SV needs the be decompressed as access to the artery and plexus are better served via the TA or with a separate SC incision. The IC incision can be combined with a SC approach – the PC. This enables more complete first rib resection than can be through the other individual approaches. Furthermore, as the SV is directly exposed, reconstruction can be performed as well.