Patients with acute Paget-Schroetter syndrome (PSS) are treated with endovascular therapy and first rib resection (FRR); however the care of patients with chronic PSS is less well understood. This report describes an emerging approach of robotic-FRR, with adjuvant endovascular therapy, for chronic PSS.A single-center, retrospective analysis was conducted of patients undergoing robotic-FRR for chronic PSS between 2017 and 2020. Chronic PSS was defined by subclavian vein (SCV) fibrosis identified on duplex ultrasound examination. Patency and clinical outcomes were compared before and after robotic-FRR.Fifteen robotic-FRRs in 14 patients with chronic PSS were analyzed. Median time between acute thrombosis and presentation to our clinic was 167 days. Eleven SCVs were previously treated with anticoagulants only, and 4 had a history of thrombolysis. At the time of presentation, all SCVs displayed chronic thrombosis on duplex ultrasound; 7 (46.7%) were treated with angioplasty followed by robotic-FRR, and 8 (53.3%) proceeded first to robotic-FRR. Postoperative duplex ultrasound examination at a median of 34 days from robotic-FRR demonstrated patency in 5 (33.3%) SCVs. Postoperative angioplasty was performed in 9 (60%) SCVs after a median of 59 days from robotic-FRR, resulting in 6 (40%) additional patent SCVs. The total number of SCVs achieving patency was 11 (73.3%). There were no complications during angioplasties or robotic-FRR. Eleven patients (73.3%) achieved complete symptom resolution with decrease in swelling (P < .001) and pain (P = .016).Robotic-FRR in combination with adjuvant endovascular therapy was associated with favorable clinical and patency outcomes for chronic PSS.