Seven patients with symptomatic bilateral internal carotid artery occlusion had 11 extracranial operations involving carotid, vertebral, and subclavian arteries. A priority approach to the extracranial vessels was followed. Priority was given to the correction of subclavian steal when present. An external carotid angioplasty or bypass was given priority if its origin was stenotic or occluded. If both vertebral arteries, or the dominant one, had stenoses at their origin greater than 75% of the cross-sectional area, a subclavian-vertebral artery bypass was performed. When both internal carotid arteries are occluded, the external carotid and vertebrovasilar systems are the main collaterals and are often also stenotic. Correction of these occlusive lesions in the collateral pathways produced complete symptomatic relief in these patients. In two selected cases with specific angiographic findings and a normal blood pressure, immediate internal carotid thromboendarterectomy was performed. No morbidity or mortality was encountered in these seven patients.