To demonstrate a direct operative approach to vascular lesions of the internal carotid artery (1CA) at the level of the skull base. Between January 1993 and October 1999, five patients underwent lateral skull base resection with cervical-to-petrous carotid artery saphenous vein bypass for repair of distal 1CA lesions. This report describes operative methods, morbidity, graft patency, and long-term outcome with this experience. Of the five patients with skull base ICA lesions, all had aneurysmal disease. Three were atherosclerotic and two were dysplastic. Preoperative neurologic symptoms including transient ischemic attacks (2) and Horner's syndrome with vascular headaches (1) were completely resolved after operation. Preoperative dysphagia (2) was resolved in one patient and clinically improved in the other. Postoperative complications included transient paresis in the cranial nerve (CN) VII distribution, as well as permanent loss of the eustachian tube and chorda tympani nerve in all five patients. One patient had lasting paresis in the CN XI distribution as well as a mild stroke resulting in arm weakness. No residual arm weakness was detected at one year. There were no graft occlusions by duplex ultrasound at 45.8 months mean objective follow-up, and no ipsilateral stroke or mortality at 51.2 months mean clinical follow-up. Saphenous vein bypass from the cervical-to-petrous ICA is technically feasible and provides a valuable reconstruction option for patients with skull base ICA lesions. © 2002, SAGE Publications. All rights reserved.