Atherosclerotic occlusive disease of the upper extremity can be a challenging and complex problem for the vascular surgeon. Due to the variety of pathologies that can affect the upper extremity, an accurate diagnosis may be difficult to obtain. We describe the case of a 52-year-old white man who presents with a pulsatile mass on the volar aspect of the right wrist. Arteriography of the aortic arch and right upper extremity revealed an 80% atherosclerotic stenosis at the origin of the right subclavian artery, as well as occlusion of the superficial radial artery. The occlusion resulted in the formation of an aneurysmal collateral, which communicated with the superficial palmar arch. A right carotid-subclavian bypass was necessary to prevent further embolic phenomena. The radial artery aneurysm was treated by resection and primary repair.