Conclusion: Patients with cervical carotid artery stenosis undergoing conventional carotid endarterectomy (C-CEA) have better periprocedural outcomes than those undergoing eversion CEA (E-CEA). However, E-CEA may be more efficacious for long-term prevention of ipsilateral stroke. Summary: There are two basic techniques for CEA: C-CEA is performed through a longitudinal arteriotomy and is generally closed with a patch, and E-CEA is performed with an oblique transection of the internal carotid artery off the common carotid artery with reimplantation of the endarterectomized internal carotid artery onto the common carotid artery. A Cochrane review in 2009 concluded that there was no evidence that one technique was superior to the other with respect to periprocedural stroke, death, or restenosis (Cao P et al, Cochrane Database Syst Rev 2002;1:CD001921). In this report, the authors present a post hoc retrospective analysis of the surgical arm of the Stent Protected Angioplasty versus Carotid Endarterectomy trial (SPACE-1). All patients in the SPACE-1 trial were symptomatic, and choice of CEA technique in the surgical arm was based on surgeon preference. There were 601 eligible patients randomized into the surgical arm of the SPACE-1 trial. After excluding patients who withdrew consent before treatment, who did not undergo per-protocol treatment, who experienced primary outcome before treatment, or who had CEA without patch closure or prosthetic bypass graft interposition, there were 516 patients suitable for analysis. Of these, 310 (60.1%) underwent C-CEA and 206 (39.9%) underwent E-CEA. The primary end point was ipsilateral stroke or death ≤30 days after surgery. Secondary end points included perioperative adverse events and the 2-year risk of restenosis, stroke, and death. There were no restrictions with respect to type of anesthesia, neurologic monitoring, heparin dose, type of patch to close the arteriotomy, or indications for shunting. The C-CEA and E-CEA groups were similar in demographics and baseline clinical variables. Shunt frequency was higher in the C-CEA group (65% vs.17%; P < .0001). Ipsilateral stroke or death ≤30 days were significantly greater with E-CEA than C-CEA (9% vs 3%; P = .005). There were no statistically significant differences in perioperative secondary outcome events between the two groups with the exception of a higher risk of intraoperative ipsilateral stroke in the E-CEA group (4% vs 0.3%; P = .0035). The 2-year risk of ipsilateral stroke after 30 days was higher in the C-CEA group than in the E-CEA group (2.9% vs 0%; P = .017). Including perioperative events at 2 years, there were no differences between groups in ipsilateral stroke, any stroke, disabling stroke, death, or any stroke or death. Comment: The study is interesting in that it suggests that the choice of CEA technique may influence periprocedural events but not long-term ipsilateral stroke or overall death. The limitations of this study are obvious: it used a nonrandomized post hoc analysis, with no information about why one CEA technique was chosen over the other, and lacked a blinded outcome assessment. The authors also note that an infinite hazard ratio confidence interval for ipsilateral stroke >30 days and the wide odds ratio confidence intervals for death rates indicate that, statistically, a substantial technique-dependent effect has not truly been ruled out by this study. Nevertheless, this was an independently monitored, multicenter study and therefore may have more generally applicable and accurate data than a single-center study.