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Surgery for thoracic outlet syndrome (TOS) is claimed to have a low risk of severe complications. To re-evaluate this, a questionnaire was sent out to the French vascular surgical community. There were 66 replies. While some surgeons had operated on several hundred patients without any severe complications, others had experienced rare but dramatic complications including wounds or thrombosis of the axillary artery, vein injuries or thrombosis, transient or definitive paralysis of the brachial plexus, long thoracic or phrenic nerves, hemothorax, and chylothorax. Two resulted in the death of young patients. The results of the present study, as well as rare reports in the literature, demonstrate that these complications may occur even with experienced surgeons using either the supraclavicular or transaxillary approaches. We conclude that: (1) operation for TOS should be considered only when the diagnosis is certain and when operative decompression is the sole solution; (2) the choice of an adequate approach, good vision during operation, and meticulous technique are all mandatory for full security. Surgical guidelines are suggested.