Symptomatic carotid artery disease stenosis warrants open surgical carotid endarterectomy (CEA). However, patients with continuous-flow left ventricular assist devices (CF-LVADs) present unique challenges when vasopressors and volume are used to maintain cerebral perfusion pressure after carotid cross-clamping. This report describes patients with CF-LVADs who underwent CEA. We identify how preload, contractility, afterload, pump speed, mean arterial pressure, and anticoagulation should be addressed to maintain CF-LVAD outflow and cerebral perfusion during the procedure. Anesthesiologists can combine an understanding of continuous-flow physiology with invasive monitors to optimize cardiac output and cerebral blood flow during CEA procedures.