The significant risk of fatal myocardial infarction after carotid endarterectomy in patients with coronary disease long has been recognized. In 1,546 consecutive carotid endarterectomies performed in 1,238 patients over the last 10 years, angina pectoris was present in 17% (212/1,238) of patients; a further 32% (396/1,238) of patients were asymptomatic, but had a history of myocardial infarction. The perioperative mortality (30 day) in the 1,306 consecutive endarterectomies in 1,026 patients without symptomatic coronary artery disease was 1.5% (15/1,026 patients). Of the 212 patients with symptoms, 85 carotid endarterectomies were performed in 77 patients without prior coronary bypass operation with an operative mortality of 18.2% (14/77 patients). The remaining 135 patients had 155 carotid endarterectomies but were treated by either prior coronary artery bypass (84 patients) or simultaneous carotid endarterectomy and coronary artery bypass (51 patients) with an operative mortality of 3% (4/135 patients). The greatly improved survival in those patients with symptomatic coronary disease who had a coronary artery bypass prior to or at the same time as carotid endarterectomy, and the absence of permanent neurological deficit in the 51 of these 135 patients who had simultaneous carotid endarterectomy and coronary artery bypass suggests that significantly improved survival can be achieved after carotid endarterectomy in these high risk patients by the use of simultaneous coronary artery bypass surgery.