Symptomatic arterial occlusive disease of the supra-aortic trunk vessels, namely, the brachiocephalic artery (BCA), proximal left common carotid artery (LCCA), and proximal left subclavian artery (LSCA), may manifest as neurologic events such as stroke, transient ischemic attack, or vertebrobasilar insufficiency when the cerebral hemispheres are involved or tissue loss or effort fatigue when affecting the upper extremities. While infrequently encountered in the routine practice of most vascular surgeons, a knowledge of the treatment options available including both extra- and transthoracic open arterial reconstructions and endoluminal arterial reconstructions is necessary in order to provide the optimal care for patients presenting with this disease process. The location and extent of the disease as well as patient’s overall physical condition are factors in the choice of repair.