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OBJECTIVES: Presentation of a case of carotid stenosis in an elderly patient with multiple co-morbidities, and its management. METHODS: Pre-operative management of an elderly patient affected by carotid artery stenosis with cardiac, metabolic and renal comorbidities and a recent history of buccal squamous carcinoma. RESULTS: Pre-operative anestesiologic assessment showed an increased risk for the presence of heart failure, cardiogenic pulmonary hypertension, mild/moderate stage renal disease. CONCLUSION: The frail elderly represents a real challenge for the surgeon, because in choosing treatment other options must be taken into account both in view of local disease and of various systemic comorbidities.