This chapter discusses management of the carotid artery in advanced head and neck cancer, where patients with advanced head and neck malignancy who have carotid artery involvement show dismal prognosis. In order to choose the appropriate management strategy carotid artery involvement should be assessed. A sentinel bleed is a classical warning sign of an imminent blow-out. In many patients, the carotid artery is either displaced or surrounded by the tumor mass. The obliteration of the fascial plane between the tumor and the carotid artery, and circumference of tumor attachment to the artery are radiological features used to predict tumor invasion. Electroencephalography and sensory somatic potentials have also been used to show cerebral ischemia. Positron emission tomography during balloon occlusion has been used in order to determine the cerebral blood flow. The major neurological complications include coma and hemiplegia Intraoperative arteriography is performed in order to assess the technical results.