Of 79 patients seen at the University of Minnesota with symptomatic chronic obstruction of the axillary subclavian or innominate vein, 65 were considered surgical candidates. Etiology of the obstruction was as follows: Group A (n = 45), previous subclavian effort thrombosis; Group B (n = 14), stenosis caused by occupation or sport activities; and Group C (n = 6), long segments (4-7.2 cm) of obstruction caused by chronic intraluminal placement of devices (catheters, pacemaker, or defibrillator leads). Fifty-nine patients (Groups A and B) underwent, via a subclavicular incision, removal of the first rib and vein patch angioplasty. Six patients (Group C) needed to have the incision extended transsternally to expose the entire length of the obstructed vein. In four of them, the subclavian-innominate vein was replaced with a cryopreserved small thoracic aortic homograft. In the other two, a long vein patch was used. The long-term success rate with the standard subclavicular incision (Groups A and B) was 85%; with the extended incision (Group C) it was 83% (patency of homograft, 100%; with the patch, 50%). In nine patients the vein occluded postoperatively (15%) due to inadequate exposure. We designed a new extended approach through the sternum in six patients and achieved a 100% success rate.