Concern about the increasing number of carotid endarterectomies (CEs) performed in the USA has placed considerable pressure on physicians to limit the number of CEs they perform. However, CEs have prophylactic values in asymptomatic patients. Thus, a major question facing a clinician is to decide when to operate on asymptomatic patients with carotid bruits. The decision is not yet clear-cut, but new data are available. Other controversial issues presented here are choice of anesthesia, patient evaluation and management, and techniques for brain and heart preservation.