A five year experience with 20 patients who had penetrating vascular injuries of the thoracic outlet was reviewed. A median sternotomy with extension into the right neck was used to explore six patients with right subclavian vascular injuries. With injuries to the origin of the left common carotid artery, repair was accomplished through a median sternotomy combined with a left anterior thoracotomy in one patient and through a left posterolateral thoracotomy in the other. Injury to the left subclavian vessels occurred in five patients and was exposed through a left anterolateral thoracotomy combined with a supraclavicular incision in four patients and through a supraclavicular incision with clavicular resection in one patient. Axillary vessel trauma generally was managed with an extrathoracic incision only. The two deaths in this series were due to postoperative respiratory complications (mortality rate of 10%). Twenty arteries were repaired and all were patent on follow-up examination. Associated neural and venous injury caused significant morbidity in 28% and 10% of patients, respectively. As a result of this experience we continue to recommend an extended median sternotomy for repair of right-sided cervicothoracic vascular injury. Anterior or posterolateral thoracotomy combined with a supraclavicular incision is advocated for trauma to left-sided vessels of the thoracic outlet. When possible, injured veins should be repaired rather than ligated.