Occlusion of the common and internal carotid arteries in a patient with symptomatic severe cerebral ischemia, with or without contralateral carotid disease, portends a poor prognosis. The present study has described our experience with subclavian and external carotid artery revascularization for symptomatic severe cerebral ischemia from common and internal carotid artery occlusion. Nine patients (five men and four women) with a mean age of 62 (range 41 to 82 years) were diagnosed as having symptomatic severe cerebral ischemia. All patients had ipsilateral hemispheric symptoms, seven had amaurosis fugax, and two had associated syncope. Four patients (three men and one woman) were hypertensive, four (two men and two women) had diabetes, eight smoked, and all had a history of coronary artery disease. All of the patients had noninvasive laboratory studies and preoperative angiography, and three had postoperative angiography. Five patients were successfully revascularized to a patent external carotid artery despite nonvisualization by angiography. Six patients had unilateral and three bilateral occlusion of the common and internal carotid arteries appropriate to their symptoms. Using regional anesthesia, four patients underwent a subclavian-external carotid bypass with polytetrafluoroethylene; saphenous vein was used in five; and three had concomitant axilloaxillary bypass grafting with polytetrafluoroethylene. Neurologic improvement (that is, no subsequent deficit and no progression of symptoms) was noted in all nine patients with a follow-up of 4 to 28 months (mean 11.2 months). Two patients died from myocardial infarction 4 and 7 months after operation. Subclavian-external carotid artery bypass is a safe addition to the options for the treatment of symptomatic severe cerebral ischemia with occlusion of the common and internal carotid arteries, visualization of a superior thyroid collateral vessel on the recipient end, and nonvisualization of the external carotid artery.