Invoking unacceptable operative risks, many institutions have adopted a conservative policy toward carotid stenosis in patients who require cardiopulmonary bypass (CPB). We have continued to apply simultaneous carotid endarterectomy/coronary artery bypass grafting (CEA/CABG) in selected patients, and in order to place operative risk in perspective, our experience with CEA/CABG was reviewed and contrasted with both CEA and CABG performed as isolated procedures. Seventy-one CEA/CABG were performed from 1978 to 1987, with the bulk of the experience (51/71) accumulated over the past 5 years. CEA/CABG was applied when the carotid lesion was severe (greater than or equal to 75% diameter stenosis). Clinical characteristics of patients with CEA/CABG (e.g., presence of unstable angina, left main coronary artery disease, and impairment of ventricular function) suggested these patients were at higher risk for complications when compared to patients with CABG alone. Yet, other factors influencing stroke risk during cardiopulmonary bypass (patient age, duration of CPB time) were similar between patients with CEA/CABG and patients with only CABG. Most complications in patients with CEA/CABG occurred in the early years of the study. Considering the recent (1983-87) patient cohorts of CEA/CABG and isolated CABG, respectively, there was no significant difference in either operative mortality (2.0% as compared to 2.2%) or perioperative stroke (2.0% as compared to 0.6%). Whereas precise patient selection criteria remain undefined, these findings verify the safety of the combined CEA/CABG approach for most patients who require treatment of both lesions.