The records of 421 patients who underwent carotid endarterectomy were reviewed. Between 1967 and 1972 carotid endarterectomy was performed with regional anesthesia in 232 patients. Ten per cent of these patients required the use of general anesthesia and a temporary indwelling shunt, because of the development of neurologic symptoms after temporary cross-clamping (5.6%) or the inability to tolerate regional anesthesia (4.3%). The 30-day mortality was 2.6 per cent. The incidence of fixed neurologic deficits was 2.2 per cent, and the incidence of transient neurologic deficits was 3 per cent. Between 1974 and 1976, 189 carotid endarterectomies were performed with general anesthesia and the routine use of a temporary indwelling shunt. The 30-day mortality was 0.5 per cent. The incidence of fixed neurologic deficits was 2.6 per cent; the incidence of transient neurologic deficits was 2.6 per cent. The use of general anesthesia with a shunt has not significantly changed the mortality or incidence of postoperative neurologic complications when compared with the authors' series performed with regional anesthesia. All patients in whom postoperative strokes occurred had multiple stenotic or occlusive lesions. Special precautions should be taken in this high-risk group.