Although several randomised trials had established the role of carotid endarterectomy in the prevention of stroke, reports of operative risk of 2 to 8% from these studies demonstrate the need for further investigation into the cause of perioperative stroke. The use of a shunt during CE has been an established practice to protect the patients from ischemic events. However, its use remains controversial because of embolisation or intimal damage. Considering the shunt placement in the presence of common carotid artery disease as a potential cause of distal embolisation, we reported a review of all patients with internal carotid artery stenosis 470% associated with a common carotid artery disease in whom a carotid endarterectomy was performed using a temporary brachial to internal carotid artery shunt (external shunt, ES) (Fig. 1).