BACKGROUND Although carotid endarterectomy is increasing in the UK, there is evidence that the procedure is still underused. Methods of reducing cost in a single vascular unit have been assessed using a continuous audit including outcome measures. METHODS A consecutive series of 333 patients admitted over 7 years under a single consultant surgeon were studied. Outcome measures included the rate of perioperative neurological complication of any kind, and death. The length of hospital stay and the number of readmissions within 30 days were recorded prospectively by computerized audit. RESULTS Over the interval of the study, the number of preoperative investigations was reduced; angiography and cerebral computed tomography were reserved for specific indications. The median duration of hospital stay decreased from 7 to 2 days. There was no change in the stroke and death rate (3 per cent) during the study and only two patients required readmission within 30 days. CONCLUSIONS Carotid endarterectomy can be performed cost-effectively using non-invasive preoperative investigations for the majority of patients. In-hospital stay has been reduced and the routine use of intensive care replaced by a 2-h stay in theatre recovery. These changes have been achieved without compromising patient safety.