When claudication or distal ischemia is significant, the treatment of choice for intrinsic arterial insufficiency of the upper extremity caused by atherosclerotic occlusive disease of the subclavian, axillary, or brachial artery with patent distal circulation is direct arterial surgery. Both endarterectomy and bypass procedures are utilized. In the 20 years from 1947 to 1967, 15 patients were operated on for such lesions and adequate circulation was restored in 12 patients treated by the direct method. Nine patients available for 1-year follow-up were cured of their symptoms; of the remaining three patients, one had amputation of an arm and two had sympathectomy with improvement. No hospital death occurred and morbidity was minimal. Although the diagnosis can be established on clinical grounds, arteriography is essential to ascertain the surgical procedure needed. Peripheral diseases involving the small arteries are clinically a more common cause of arterial insufficiency in the upper extremity; progress is slow and complications are infrequent. When ischemic complications exist, direct arterial surgery is not feasible and cervicodorsal sympathectomy is the usual form of treatment. Of 76 patients operated on for such disease, 74 underwent sympathetic neurectomy. The results were excellent, good, or satisfactory in 50 (78%) of the 64 traced patients. The remaining 14 patients had persistent or recurrent symptoms after operation. Removal of the stellate ganglion in addition to the second ganglion yielded better results and is indicated in recurrent or more cases.