The patient presents with symptoms of global cerebral hypoperfusion and unable to obtain blood pressures in bilateral upper extremities. Her diagnostic workup included carotid ultrasound and CTA of the chest. Her carotid ultrasound demonstrated reversal of flow in the right internal carotid artery and her CTA identified a significant, diffuse plaque of the innominate and left common carotid arteries. She was deemed an appropriate candidate for direct trans-sternal revascularization based on PFT's, ECHO and coronary catheterization. A midline sternotomy was performed and the ascending aorta dissected out. The innominate vein was retracted caudad and the innominate, right subclavian, right common carotid and left common carotid arteries were dissected out. The patient was heparinized followed by placement of a side-biting aortic clamp. The proximal anastomosis of our bifurcated Dacron graft was performed with running Prolene suture and then flushed. Our graft limbs were then sewn to the right subclavian and left common carotid arteries with reimplantation of the right common carotid artery into the aorto-subclavian limb. The patient tolerated the procedure well and was discharged to rehab on post-operative day seven. She had palpable right upper extremity pulses and resolution of her global cerebral hypoperfusion symptoms.