Background Stroke is the second leading cause of death worldwide, with 10% of neurologic events occurring in adults aged 18–49 years. The incidence in this age group has risen over the last 2 decades (while falling in the aged), despite improved diagnostic capacity and greater ability to treat it medically and surgically. We are unaware of any modern data regarding the risk factors and outcomes after carotid artery surgery in this demographic. We sought to evaluate the contemporary characteristics and outcomes of young adults undergoing carotid surgery. Methods Retrospective analysis of patients aged 18–49 years who underwent carotid surgery from 2005 to 2015. We collected demographics, indications, and outcomes, comparing them to previously published series. Results Sixteen patients were with the mean age of 46 (41–49) years, and 44% were male. Most were Caucasian (88%) and smokers (94%), consuming 1.3 packs/day with a mean pack-year history of 32 years (10–100). Average body mass index was 29. The majority (81%) were symptomatic prior to surgery (69% of these were strokes). Complications after surgery were hyperperfusion (1) and one deep vein thrombosis. Compared to young patients treated from 1973 to 1990s, we found significantly more female patients (P < 0.001) and more strokes (P < 0.04) leading to the procedure, while smoking remained the most prevalent risk factor. Conclusions Carotid artery surgery in young patients continues to be associated with symptomatic stenosis and smoking; however, compared to 2–4 decades ago it may be more common in young females, and following a stroke. This may be from an increased prevalence of female smoking and improved neuroimaging.