Despite abundant published support of patch angioplasty during carotid endarterectomy (CEA), primary closure is still widely used. The reasons underlying the persistence of primary closure are not quite evident in the literature. To present our experience with primary closure in CEA, and provide a rationale for its persistent wide use. Medical records of all patients undergoing CEA by the senior author (R.F.) were retrospectively reviewed. Follow-up was supplemented with a telephone interview and completion of a structured questionnaire. A review of the current literature was performed. From 1998 to 2010, the senior author performed 111 CEAs. Average cross-clamp time was 33 ± 11 minutes. Postoperative complications included 1 non-ST-elevation myocardial infarction and 2 strokes. No deaths, cranial-nerve deficits, or acute reocclusions were observed. After a mean follow-up of 64.6 months (7170.6 case-months), there were 3 contralateral strokes and 7 deaths. There were no ipsilateral strokes or restenoses >50%. Follow-up medication compliance was 94.6% for antiplatelet agents and 91.9% for statins. The outcomes of the current study were comparable to those of the available trials comparing patch angioplasty with primary closure. A careful evaluation of the literature revealed a number of reasons potentially explaining the persistent use of patch angioplasty. In conjunction with contemporary medical management, primary closure during CEA may yield results comparable or superior to patch angioplasty. Advantages of primary closure include shorter cross-clamp times and elimination of graft-specific complications.