Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon: hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13-year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed non-operatively with anticoagulation.