The most effective treatment of patients with stroke due to tandem occlusion is still unclear. We report the case of a man with stroke due to tandem internal carotid artery/middle cerebral artery occlusion, who underwent initially ineffective intravenous thrombolysis (IVT) and endovascular treatment. Early anticoagulation with apixaban was started after 48 h of IVT, given a newly diagnosed nonvalvular atrial fibrillation. Spontaneous partial recanalization of the cervical internal carotid artery was noted, and carotid endarterectomy was performed 72 h after IVT and 8 h after the last dose of apixaban. Surgery was conducted without any complication and the patient was discharged 7 days after onset with a residual mild hemiparesis. This is the first report of urgent carotid endarterectomy in an anticoagulated patient receiving a direct oral anticoagulant. This case highlights the importance of an early multidisciplinary approach to achieve a successful treatment of stroke due to tandem occlusion.