Purpose of this study. Occlusive disease of the innominate artery requiring reconstruction is relatively uncommon. Data concerning these lesions has come from retrospective reviews at larger institutions. The purpose of this paper is to review the most recent experience at the Mayo Clinic, as well as to review the experiences of other large centers in the recent past, and to determine which patients are benefited by direct reconstructions and which patients might be better served by indirect methods or by endovascular techniques. Basic methods: A retrospective analysis of the trends at the Mayo Clinic concerning reconstruction of the innominate artery since 1976 was undertaken. Two reviews from our institution, published in 1989 and 1999, of all patients seen since 1976, were analyzed. This retrospective analysis also included papers from other referral centers dealing with innominate artery reconstruction, both here and in France. Principal findings and conclusions: The great majority of patients with symptomatic disease of the innominate artery are well treated by direct reconstruction. Stroke and death rates are acceptable. Early results are excellent, and the durability of the operation is also excellent, with impressive stroke-free survival rates. There are subsets of patients who might be treated by medical techniques or techniques other than direct reconstruction, such as cervical reconstruction or endovascular repair. Coronary artery disease remains the main determinate of early and late morbidity.