The management of patients with combined carotid and coronary artery disease remains controversial. Up to 28% of patients presenting for carotid endarterectomy (CEA) have severe reconstructible coronary artery disease, and up to 22% of patients presenting for coronary artery bypass grafting (CABG) have severe carotid artery disease. Myocardial infarction is the most common cause of early and late mortality after CEA. Stroke after CABG is a devastating and dreaded complication. Duplex ultrasound testing prior to coronary revascularization is recommended. The 3 options for treatment include the staged approach (CEA followed by CABG), the reversed staged approach (CABG followed by CEA), and the combined approach (CEA and CABG during the same anesthetic). The result of each of these approaches varies widely and primarily depends on patient selection. A policy of CEA prior to CABG is justified only in patients with stable coronary disease, good ejection fraction, and is best-performed using regional anesthesia. The combined approach is well accepted in those patients with severe, symptomatic disease in both the carotid and coronary artery disease. Off pump coronary revascularization has emerged as a viable option in the treatment of coexisting clinically significant carotid and coronary artery disease. The main goal of this study is to compare the results of different surgical approaches and to choose the best approach to treat combined carotid and coronary artery disease and to minimize the incidence of complications such as myocardial infarction, stroke, congestive heart failure, arrhythmias and others. 30 cases were in room in this study. 17 cases in stage approach. Complicated by 1 case myocardial infarction and 1 case by nerve dysfunction and 1 case mortality, and 1 case hematoma, 6 cases in reserved staged approach and no complication was done and 7 cases in combined approach and complicated by 1 case stroke and 2 cases hematoma.