Background The aim of this retrospective observational study was to assess whether patients ≥ 75 years of age had a significantly inferior 5-year stroke free survival rate compared to patients <75 years of age after carotid endarterectomy under regional anesthesia. Methods All consecutive patients with asymptomatic high-grade internal carotid artery (ICA) stenosis operated on from January 1997 to December 1999. Of 273 consecutive patients with asymptomatic carotid artery stenosis, follow up was complete for 253 patients. Results Of 253 patients, 152 were younger and 102 older than 75 years at surgery (65 ± 8 years (range 43–74) and 79 ± 4 years (range 75–90); P < 0.001), respectively. Perioperatively, 4 patient developed stoke (1.6%), 2 in each group (1.3% and 1.6%, respectively). Of all patients in the below 75 group, both carotid territories were asymptomatic in 108 (72%), in 43 patients (28%) the contralateral territory was symptomatic (TIA or stroke). For the patient group above 75 years, 89 (87%) were asymptomatic bilaterally and 13 (13%) had a contralateral symptomatic carotid territory. Ipsilateral stroke free survival for all 253 patients was 55 ± 13 months in the below and 49 ± 19 months (P = 0.013). When only assessing bilaterally asymptomatic patients, ipsilateral stroke free survival was 54 ± 14 months in the younger and 50 ± 18 months in the older patient group (P = 0.15). Conclusion Age alone was not a predictor of inferior long-term outcome after carotid endarterectomy for asymptomatic high-grade stenosis. However, patient selection is crucial. If adhered to epidemiological data for risk factors of stroke and death, patients with a mean age of ≥ 75 years can be treated safely with acceptable long-term results. In the analyzed population older patients with a contralateral symptomatic carotid territory have a significantly inferior 5-year ipsilateral stroke free survival compared to patients < 75 years at surgery.