In the absence of randomized data, the optimal management of patients with severe carotid and coronary artery disease (CAD), especially those undergoing coronary bypass grafting (CABG), remains unsettled. As a general rule, in patients with multilevel atherosclerotic disease the symptomatic vascular discrict should be treated first. The entirely surgical approach with carotid endarterectomy (CEA) and CABG is associated with high event rates. Therefore, whenever in the work-up prior to cardiac surgery severe carotid disease is identified, the indication for CABG should be reassessed and the feasibility of percutaneous coronary intervention (PCI) as an alternative treatment should be explored. If PCI is not an option, carotid artery stenting (CAS) prior to open heart should be considered if the expertise is available. Although perioperative stroke is multifactorial and the value of revascularization of asymptomatic carotid disease prior to open heart surgery remains controversial, treatment of patients with severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention. The aim of carotid revascularization in patient with unilateral severe carotid stenosis should more long-term stroke prevention than merely perioperative stroke reduction. The main advantage of CAS compared with CEA in patients with advanced CAD is the reduction of perioperative myocardial infarction, an event associated to long term mortality.