In this retrospective series of 46 patients with neurovascular injury of the thoracic outlet or axilla, our management strategy emphasized prompt recognition of trauma that may be superficially innocuous. Whenever possible, the precise site of vascular injury was identified arteriographically to help plan an incision that would provide proximal vascular control as well as expedient injury exposure. Vascular reconstruction was accomplished with either end-to-end primary anastomosis (n = 17) or autogenous saphenous vein graft interposition (n = 26). No case of ischemic limb loss occurred, although two repairs failed. Primary neural repair (n = 4) was possible only with simple laceration, but decompression of a tense hematoma led to prompt resolution of neuropraxia in nine patients. Secondary neural reconstruction was largely unsuccessful, and approximately 25 percent of our patients had serious chronic disability related to neural injury. In addition, two patients died as a consequence of numerous associated injuries.