Summary Despite the recent controversy concerning surgical therapy of patients with carotid artery disease, rational therapeutic plans can be developed based on available data. Patient who is symptomatic from occlusion of one or both internal carotid arteries is at particularly high risk for development of stoke and can ill-afford in-decision. All symptomatic patients, therefore, with any of the extracranial occlusive disease patterns described are potential surgical candidates. Conversely, among the asymptomatic patients with these same patterns of occlusion, only those with internal carotid occlusion and contralateral stenosis should be considered for surgical therapy. Treatment must be individualised and directed at revascularising stenotic (not occluded) internal carotid ateries, or important collateral vessels such as the external carotid artery and in fewer cases the vertebral artery. The asymptomatic patient with unilateral internal carotid artery occlusion and no contralateral lesions should be monitored closely with Duplex scanning for development of a contralateral stenosis. When a stenosis of 80% or greater is encountered, strong consideration should be given to prophylactic endarterectomy in these patients due to their high risk for stroke. Endarterectomy for a 50–60% stenosis may also be reasonable in a single patent internal carotid artery. In the absence of a significant contralateral stenosis, no treatment is necessary. Individuals with internal carotid artery occlusion and symptoms referable to a contralateral carotid stenosis should also be manage with endarterectomy of the stenotic carotid artery. If, however such a patient presented with retinal or cerebral hemisphere ischaemic symptoms ipsilateral to an occluded internal carotid artery and compromised external carotid artery, reconstruction of the latter would be appropriate therapy. Similarly, the symptomatic patient with bilateral internal carotid artery occlusion may be succesfully treated wih revascularisation of a stenotic external carotid artery, obliteration of an internal carotid artery stump wich may be an embolic source, and in some cases vertebral artery reconstruction.