An 88-year-old male presented to the Emergency Department with episodes of transient neurological symptoms including confusion, unsteadiness, right arm numbness and left monocular vision loss. CT showed bilateral internal carotid artery (ICA) origin stenosis, worse on the left, with an incidental 22 x 17 x 24mm mass at the left carotid bifurcation consistent with a carotid body tumor (CBT). Given symptomatic left ICA stenosis with an ipsilateral CBT, decision was made to treat both simultaneously. The external carotid artery was ligated and divided, and the carotid bifurcation was resected and replaced with a polytetrafluoroethylene graft. There was insufficient great saphenous vein length bilaterally for an autologous graft. Intraoperatively the ICA was 90% stenosed with liquid atheroma and intraplaque haemorrhage. Total operation time was 68 minutes. The patient recovered well with no cranial nerve injuries and was discharged on day two. Pathology confirmed a carotid body paraganglioma. A six-week follow up carotid doppler ultrasound showed a patent graft without stenosis. Symptomatic ICA stenosis with a concurrent ipsilateral CBT is rare and complicates surgical planning. There are only three other reported cases in the literature. Two were treated with a carotid endarterectomy followed by simultaneous CBT resection [1]. The other had an endovascular carotid stent procedure first, then dissection of the CBT ten weeks later [2]. No prior cases using an interposition carotid graft have been reported. This case demonstrates an approach to treat a symptomatic ICA plaque and an ipsilateral CBT simultaneously with a carotid interposition graft. This approach may reduce embolic risk and shorten operative time by avoiding excessive carotid plaque and tumour manipulation by using an ‘en bloc’ resection. References 1. Hinojosa C, et al. Vasc Endovasc Surg. 2017;51:103–107. 2. Maxwell G, et al. J Am Coll Surg. 2004;198:36–41.