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From May 1964 to June 1983, 36 carotid-subclavian bypasses were done in 36 patients who had symptomatic lesions at the origin of the common carotid and/or subclavian arteries at the Center for Health Sciences of the University of California, Los Angeles. Ages ranged from 28 to 82 years (mean, 58 years). Eighteen bypasses were done with prosthetic grafts, 13 done with autogenous vein, and five were transpositions with primary anastomosis of the subclavian and carotid arteries. Follow-up was available on all patients and ranged from 9 to 156 months (mean, 51.5 months). The graft patency rate at 5 years determined by actuarial methods and documented by clinical examination, noninvasive evaluation, and/or arteriography was 94.1% for prosthetic grafts and 58.3% for vein grafts (p less than 0.01). The 5-year cerebrovascular accident (CVA) rate for patients with carotid-subclavian bypass done with prosthetic grafts was 6% in contrast to 39% for those with vein grafts (p less than 0.0545). All reconstructions done by transposition and primary anastomosis remain patent and there have been no late CVAs. We conclude that prosthetic grafts are the arterial substitute of choice in carotid-subclavian bypass. Transposition and primary anastomosis between the carotid and subclavian artery, when technically feasible, may be preferable to the use of free grafts in carotid-subclavian reconstruction.