Carotid endarterectomy is the most common vascular procedure. Recent studies have suggested that carotid endarterectomy can be performed safely, based solely on ultrasound duplex evaluation in selected patients. We evaluated 12 men and 8 women who underwent carotid endarterectomy, 12 for significant symptomatic disease and 8 for tight, asymptomatic stenosis of the carotid artery. All had duplex ultrasound scans without angiography before operation. They all survived. 2 had hoarseness due to vocal cord paralysis which resolved 5 months later in 1, while in the other it still persisted 2 months after operation. There were no other neurologic complications. During follow-up all have remained symptom-free. We conclude that clinical assessment of carotid artery stenosis with duplex ultrasound scan of good technical quality provides appropriate information on which to base carotid endarterectomy, and is a safe alternative to preoperative angiography.