From January 1979 to December 1991, 92 revascularizations of the V3 segment of the vertebral artery were performed in 91 patients through a direct transposition of this artery into the internal carotid artery (ICA). These cases represented 15.1% of 610 vertebral revascularizations and 38.8% of 280 distal vertebral revascularizations performed during this period at our institution. The sex ratio of this population was 0.59, and the mean age was 59.4 +/- 13.2 years (range 14 to 82 years). Preoperative ischemic symptoms were vertebrobasilar in 87 (94.6%) cases, exclusively hemispheric in one (1.1%), and absent in the remaining four (4.3%). One of these four patients had asymptomatic severe multivessel occlusive disease and three others underwent resection of a spinal tumor involving the vertebral foraminal canal. In 31 (33.7%) cases significant carotid occlusive disease was also present. The distal V3 segment of the artery was directly transposed into the ICA in all cases in this series. In 24 (26.1%) cases the ICA was endarterectomized during the same operation. There were no deaths or strokes in this series but there were two (2.2%) transient ischemic attacks-one vertebrobasilar and the other hemispheric. However, eight (8.7%) transposed vertebral arteries were totally occluded at early follow-up. At 1 month, among the 87 patients with vertebrobasilar insufficiency, 44 (50.6%) were cured, 31 (35.6%) were improved, and 12 (13.8%) remained unchanged. Among the 12 who were unchanged, eight (66.7%) had occlusion or stenosis of the distal transposition at the time of discharge. At 5 years, the primary patency rate in the series was 89.1% +/- 7.2%. At the time of the last follow-up, among the 87 patients with vertebrobasilar insufficiency, 50 (57.5%) were cured, 25 (28.7%) were improved, two (2.3%) had remained unchanged since the operation, two (2.3%) suffered a relapse, and eight (9.2%) exhibited vertebrobasilar symptoms of varying severity and therefore could not be considered improved. Direct transposition of the V3 segment of the vertebral artery into the ICA is a simple, safe, and reliable technique for revascularization of the distal cervical vertebral artery.