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Abstract Background and aims: The effectiveness of carotid endarterectomy (CEA) depends upon selection of patients with a high absolute risk of stroke, avoidance of delays from initial presentation to surgery and provision of surgery with a low perioperative risk of stroke. We evaluated these aspects of practice in Scottish hospitals and, by encouraging adherence to national (SIGN) guidelines, attempted to improve the effectiveness of CEA. Methods: Prospective independent survey of patient selection, pre-operative delays and surgical performance for all CEAs performed in Scottish National Health Service hospitals over two 13 month periods from September 1997 and February 1999 respectively. Results: Thirteen hospitals performed 485 CEAs in the first period and 392 in the second, equating to an overall annual rate of 79 per million population. During both periods at least 95% of patients reported symptoms of carotid territory ischaemia, but the proportion with stenoses greater than > 70% rose from 89% to 97% (p < 0.0001). The delays between referral, surgical consultation and subsequent surgery fell significantly but remained unacceptably long. The proportion seen by the surgeon within two weeks of referral rose from 36% to 43% (p=0.05) and the proportion operated on within one month thereafter rose from 35% to 49% (p < 0.0001). The perioperative combined major stroke and death rate was 3% in both periods. Conclusion: We demonstrated significant changes in practice, in line with national guidelines, which would be expected to improve the effectiveness of our national programme of CEA. There is further scope for improving performance, particularly in relation to pre-operative delays.