The US Veterans' Administration study followed by the asymptomatic carotid artery stenosis study (ACAS) and now the asymptomatic carotid stenosis trial (ACST) have all affirmed that elective endarterectomy for patients carefully selected by neurologists and operated on by skilled surgeons can prevent stroke.1^–2 ^w1 The results of ACST and ACAS are almost identical, with 5.4% absolute risk reduction for stroke in ACST compared with 5.9% for ACAS. The surgical advantage persists despite multimodal medical management with statins, platelet antiaggregants, and stringent control of risk factors. Moreover, nearly 20% of asymptomatic patients randomised to the medical management arm of ACST developed symtoms during the trial, often necessitating urgent surgery. These three randomised trials all show that if medical management has failed elective endarterectomy performed by skilled surgeons is a worthwhile additional …