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OBJECTIVE: To evaluate internal carotid artery (ICA) peak systolic flow velocity (PSV) contralateral to an index carotid artery stenosis that has been treated with carotid endarterectomy (CEA) or carotid artery stenting (CAS), and determine if a significant decrease in PSV may alter management of contralateral lesions. DESIGN: Prospective cohort. SETTING: University. Ambulatory and hospitalized patients. PATIENTS: 325 consecutive patients during study period who underwent carotid intervention and had carotid duplex evaluations. INTERVENTIONS: Carotid endarterectomy, Carotid stenting. MAIN OUTCOME MEASURE: Post intervention alteration of PSV contralateral to an index carotid artery stenosis. RESULTS: There were 203 CEA and 122 CAS procedures. All patients had carotid duplex evaluations done pre-procedure and 6 months post procedure.The change in contralateral PSV was calculated as a percent of the pre-operative value. The total drop in PSV was 0-85%. Of the total 325 patients, 157 (48.3%) patients had a drop in PSV >10% from the pre-operative value. Of the patients who had a pre-operative contralateral PSV of >230cm/sec, 60% had a decrease in PSV, and their average decrease in PSV was 51.8% following intervention on the index lesion. In 44 (28%) the drop in PSV down-staged them to a different category of stenosis, and would have altered the management of the remaining carotid lesion. No significant independent variable predicted post procedure drop in PSV. CONCLUSIONS: A significant number of patients will have a clinically relevant drop in PSV in the contralateral ICA following CEA or CAS. This could result in a subsequent intervention being unnecessary. We recommend repeating duplex evaluation of all patients prior to intervention if there has been a contralateral CEA or CAS procedure.