Experience with 192 operations of vascular reconstruction for atherosclerosis in the proximal brachiocephalic and vertebral arteries is reported. These procedures constitute only 10 per cent of operations for extracranial arterial occlusive cerebrovascular disease at the University of California, San Francisco, in the past 20 years. All patients were asymptomatic. Except for six patients with cerebral embolization from ulcerating lesions, symptoms resulted from cerebral hypoperfusion. Prevention of ultimate stroke was the primary objective of operation in patients with embolization and in patients with stenosis or occlusion of the common carotid arteries. Purely obstructive lesions in the subclavian and vertebral arteries were symptomatic only when there was bilateral involvement and the objective of operation was the relief of disabling symptoms of hypoperfusion for these otherwise essentially benign lesions. Prior correction of associated stenosis of the carotid artery often removed the need for a proximal operation. The majority of the operations were endarterectomy or transposition, or combinations of the two. Cervical bypass grafts, because of their less certain durability, were used only when a more direct operation was neither feasible nor safe.