Introduction: The efficacy of Carotid endarterectomy in the prevention of stroke has been proved by randomized control studies. There are still some variations in some aspects of the surgical procedure aiming at improving the results. One of the questions is about the best way to close the arteriotomy. Materials and Methods: This is a prospective single center study. Two groups of patients were followed up for a year post carotid endarterectomy. All patients in the study underwent general anesthesia, EEG monitoring and routine shunting. In one group the artery was closed primarily (n=42). In the other group the artery was closed over a synthetic patch (n=50). Selection of the method of closure was surgeon dependent and dictated by the caliber of the artery. The rates of restenosis were checked in the 30 days follow up, and one year post operatively. The data were compared and statistically analyzed between both groups. Results: There were no significant differences between the two groups in terms of demographics, modes of presentation or prevalence of risk factors. No intraoperative strokes in either group. 4 immediate postoperative strokes (2 in each group, p=0.858). None of them were related to thrombosis, dissection or narrowing of the lumen, as verified by immediate exploration (most probably a distally impacted embolization). One death in the patch closure group due to hemorrhagic stroke (p=0.357) and it was related to intracranial hemorrhage from hyperperfusion syndrome that can occur with any type of revascularization and not specific to any particular type of closure. No stenosis in either group at 30 days. 4 hemodynamically significant stenoses were detected in the primary closure group at one year follow up (9.5%) as opposed to none in the patch group (p=0.026). Conclusion: Although some of the primary closure advocates report that they can properly select patients for primary closure based on the size of the artery and avoiding it in female gender, yet our data show that these patients still have poorer long-term outcomes (p=0.026). Thus, we recommend the routine use of patch closure after carotid endarterectomy whenever possible, regardless the patient gender or the caliber of the artery.