U.S. Route 19W (US 19W) traverses approximately 63 miles (101 km) from Cane River, North Carolina, to Bluff City, Tennessee.

The road then proceeds north through Pisgah National Forest, connecting the communities of Elk Shoal, Ramseytown, and Sioux, to the Tennessee state line (near Spivey Gap), a 22-mile (35 km) drive of frequent curves and elevation changes.

There it leaves I-26 and continues north on the Bristol Highway, overlapped with US 11E, for 9.4 miles (15.1 km), after which it reconnects with US 19E to reform US 19 near Bluff City.

In late 1934, NC 692 was dropped along the route; then, in 1952, US 23 abandoned US 19W in North Carolina by rerouting west through Faust and Wolf Laurel, meeting back at Ernestville.

In November, the North Carolina Department of Transportation (NCDOT) stated that it expects to spend $1 billion to rebuild the two-lane highway, which could take six to 10 years.