Fifty-six asymptomatic patients were treated surgically for severe internal carotid artery stenosis in preparation for other elective surgical procedures or prior to medical management of hypertension. There was one hospital mortality and two postoperative strokes. During a follow-up period of up to six years for an average of 36 months, two patients developed mild stroke with total recovery. Fifteen patients died during the interval; none from cerebral vascular accident. Twelve patients died from acute myocardial infarction. The majority of them had a history of myocardial ischemia prior to operation. The high incidence of early and late mortality and the limited length of survival in hypertensive patients past the age of 65 years with a history of myocardial infarction makes routine carotid endarterectomy in asymptomatic patients with multiple risk factors inadvisable. In younger patients, however, not burdened with several risk factors, carotid endarterectomy is indicated for severe internal carotid artery stenosis.