Arterial repair through a sternotomy has long been considered the procedure of choice for innominate artery atherosclerotic disease. Of 22 patients presenting with 21 occlusive lesions and one aneurysm, 17 patients underwent a bypass procedure, and two, an endarterectomy through a sternotomy, whereas three patients underwent cervical procedures. Their postoperative course was uneventful. Early and late results were satisfactory. We conclude that in patients with innominate artery atherosclerotic disease, the procedure employed depends on both the type of lesion and the clinical status of the patient. In most cases, a bypass graft via a sternotomy is the best option, since endarterectomy is not always possible and risks an aortic tear or dissection. In selected cases, balloon angioplasty performed either percutaneously, combined with cerebral protection by an occlusive balloon in the carotid artery or through a carotid arteriotomy in order to flush out embolic material may be sufficient. A by-pass graft from the right to the left common carotid artery is the best procedure in patients with neurological symptoms when angioplasty seems inappropriate, and when sternotomy is contraindicated for either reasons of poor health or a prior mediastinal operation.