The type of closure after carotid endarterectomy (CEA), whether with patching primary closure or eversion resulting optimal results, remains somewhat controversial. We conducted a PubMed literature review search comparing CEA with patching versus CEA with primary closure versus eversion CEA over the past four decades with emphasis on randomized controlled trials and systematic/meta-analysis and large single center or multicenter studies. The data showed that routine carotid patching can be recommended over primary closure (level 1 evidence); however, CEA with primary closure can be used for large internal carotid arteries (ICAs)>6 mm. Moreover, selective patching with CEA lacks level 1 evidence support. No significant differences were noted among the various patch materials used (e.g., synthetic patches like dacron, ACUSEAL, PTFE, pericardial patches and vein patches) and in the stroke/death rates between eversion carotid endarterectomy (ECEA) and conventional CEA (CCEA) with patching. In addition, no significant restenosis rates were noted between CEA with patching and ECEA; however, CEA with primary closure had higher late restenosis rates. There is level 1 evidence to support CEA with patching or eversion over primary closure and there is also no significant difference between the use of various patches.