Advanced systemic atherosclerotic disease is increasing in Japan. The patients with severe carotid steno-tic lesion have frequently (30-40%) associated with coronary artery disease, especially in those with diabetes mellitus and peripheral arterial disease. The new concept of acute neurovascular syndrome is similar to that of acute coronary syndrome, and both are based on the therapeutic standpoint. It becomes more important to protect the advanced atherosclerotic patients from both cerebral and myocardial ischemia/infarction, although the technology and safety of the surgery and stenting for carotid and coronary artery is remarkably improving. Clinical evidence from Japanese large clinical research should be clarified near future. The various approaches to carotid and coronary atherosclerosis tend to be less invasive.