In a review of 1,000 carotid endarterectomies performed over a 20 year period, there was relief of transient ischemic attacks in approximately 85% of patients, an operative mortality of 1.3%, due almost exclusively to myocardial infarction, and a recurrent stenosis rate of 3.1%. Coexisting cardiac disease constitutes the greatest operative hazard. Continuous electroencephalographic monitoring is a reliable method of detecting inadequate cerebral perfusion during carotid cross clamping and for the selective use of a temporary inlying carotid shunt. An atherosclerotic plaque in the carotid system constitutes a greater risk than elsewhere in the peripheral arterial system and should not be considered an innocent lesion. Prophylactic carotid endarterectomy can be performed with almost no mortality and morbidity. Antiplatelet agents, while useful in reducing the incidence of transient ischemic attacks, do not seem to provide equal protection against stroke and death from stroke.