Summary Background Data: Symptomatic atherosclerotic occlusive disease of the innominate artery is a threatening disease pattern that offers a major challenge in achieving definitive surgical repair. To assess the evolution of treatment strategies and their outcomes for this disease, the authors undertook a review of the cumulative experience for more than 3 decades at one institution. Methods: Between 1960 and 1997, 94 patients (mean age, 62 years) underwent direct innominate artery revascularization for occlusive atherosclerotic disease to relieve neurologic (n = 85) and/or right upper extremity (n = 26) symptoms or asymptomatic critical stenosis (n = 3). The pattern of atherosclerotic involvement revealed by angiography included critical stenosis (n = 77), complete occlusion (n = 10), and moderate stenosis with plaque ulceration (n = 7). A common brachiocephalic trunk was present in five patients. Transsternal (n = 68) or transcervical (n = 4) innominate endarterectomy was performed in 72 patients and bypass grafting in 22. Forty-one patients underwent concomitant endarterectomy or bypass of innominate branches or adjacent arch vessels, and 3 had coronary bypass grafting. Results: There were three perioperative deaths (3%), all due to cardiac causes. Postoperative morbidity included four strokes (three resolved), two myocardial infarctions, two transient ischemic attacks, and one sternal dehiscence. Follow-up ranged from 8 months to 20 years. Postoperative actuarial survival: rate was 96% at 1 year, 85% at 5 years, and 67% at 10 years. Freedom from recurrence requiring reoperation was 100% at 1 year, 99% at 5 years, and 97% at 10 years. Conclusions: Innominate artery reconstruction is safe and durable when either endarterectomy or prosthetic bypass is used. The anatomic variation and disease distribution permit endarterectomy for most patients. The technique of innominate endarterectomy can be extended safely to outflow and adjacent vessels.