Surgical removal of in-stent restenosis in the internal carotid artery represents a critical and technically demanding intervention in vascular surgery. As the incidence of carotid artery stenosis continues to rise, particularly among aging population, the challenge of restenosis following stenting becomes increasingly relevant. Despite advancements in endovascular techniques, including drug-eluting stents, a subset of patients may experience restenosis, necessitating surgical intervention when less invasive options fail. This chapter focuses on the surgical techniques employed in the removal of restenotic stents within the internal carotid artery, highlighting the indications, procedural steps, and outcome associated with this complex procedure. While endovascular approaches remain the first line of interventions, surgical removal is often considered when restenosis is recurrent or refractory to other treatments, presenting a viable option to prevent further cerebrovascular events. The discussion is supported by recent literature, providing a comprehensive overview of the current understanding and evidence-based practices in managing in-stent restenosis through surgical means. Studies suggest that while surgical intervention carries inherent risks, it may offer superior long-term outcome in select patient population compared to repeat endovascular procedures.