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Thoracic outlet syndrome commonly presents with the neurogenic subtype and can be caused in rare circumstances by an anatomic abnormality such as a cervical rib, for which surgical excision is the mainstay of management. An inadequately excised first or cervical rib can result in recurrent symptoms. We have reported the case of a 30-year-old woman who had presented with symptoms of right recurrent arterial and neurogenic thoracic outlet syndrome. She underwent repeat right-sided first rib and cervical rib resection with brachial plexus neural lysis and right carotid–axillary bypass via a combined supraclavicular and infraclavicular approach. At 12 months of follow-up, improvement in her symptoms was noted.