Stroke is the leading cause of serious long-term disability in the United States. A substantial portion of strokes are caused by atherosclerotic carotid artery disease. The conventional risk factors for coronary atherosclerosis are also responsible for carotid atherosclerosis. Carotid stenosis is encountered in medical practice in either symptomatic or asymptomatic states. In symptomatic patients, medical management with antiplatelet agents does not provide adequate protection against stroke. Carotid endarterectomy can help reduce the risk of a subsequent stroke. Asymptomatic patients with severe carotid stenosis can also benefit from surgical intervention if endarterectomy can be performed at a low operative risk. In recent years, percutaneous carotid stenting using self-expanding stents has become popular for the treatment of carotid stenosis. Although this initial experience has been reported from a high-risk patient population, the results are encouraging, with acceptable periprocedural stroke rates. Moreover, emboli protection devices, modern adjuvant pharmacotherapy, and modern self-expanding stents were not utilized in these studies. With rapidly expanding technology and advances in interventional pharmacology, improvement of clinical outcome is likely. Table 3 summarizes current recommendations for carotid stenting based on a panel of cardiologists, radiologists, and vascular surgeons. At this stage, randomized trials to compare endarterectomy with carotid stenting are underway. Cautious optimism is necessary until the optimal equipment, emboli protection devices, and adjuvant pharmacotherapies are fully investigated. Until then, carotid stenting should be restricted to high-risk candidates for carotid endarterectomy, including patients with severe cardiac comorbidities, previous neck surgeries or radiation, restenosis after endarterectomy, or other technical contraindications for surgery.