Between February 1988 and March 1991, 28 patients with effort thrombosis of the subclavian vein were treated with a combined approach of thrombolytic therapy followed by surgical therapy. Three categories were seen: group I (six patients), acute stage (less than 5 days); group II (seven patients), subacute stage (6 days to 2 weeks); and group III (15 patients), chronic stage (more than 2 weeks). Group III was divided into two subgroups: subgroup A, seven patients with a short-obstructed segment (< 1/2 inch), and subgroup B, eight patients with a long-obstructed segment (1 to 6 inches). During venography a catheter is placed within the thrombus for continuous infusion of urokinase (3000 U/kg/hr) for 12 to 24 hours. After complete clot lysis, resection of the first rib via a subclavicular approach is undertaken. Vein patch angioplasty was required in two patients in group I, six in group II, and seven in group III, subgroup A. Bypass of long-obstructed vein segments was attempted in only four (group III, subgroup B). Decompression and reestablishment of normal vein caliber was achieved in 100% of groups I and II and in 86% of group III, A. In only one patient of group III, B, a saphenous vein bypass remained open (25%). Operative technique is described.