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INTRODUCTION Free floating thrombus in the internal carotid artery (ICA) has traditionally been treated via open surgical approach through a longitudinal incision and exposure similar to that for a carotid endarterectomy (CEA). In this case report, we present a novel use of transcarotid artery revascularization (TCAR) for the treatment of recurrent carotid stenosis associated with free floating ICA thrombus. CASE We describe a 67-year-old female who presented with a diagnosis of right hemispheric stroke in evolution and prior history of right CEA and a mechanical mitral valve. Imaging confirmed high grade recurrent stenosis of the right ICA with free floating thrombus. TCAR was utilized to repair both the recurrent stenosis and the thrombus. CONCLUSION Redo CEA in the face of recurrent stenosis is a challenging clinical scenario, which in this instance, was further complicated by the presence of free floating thrombus and active anticoagulation due to a mechanical mitral valve. This case report describes the successful management of ICA thrombus and restenosis with novel use of TCAR.