The optimal management of patients with symptomatic and asymptomatic carotid artery stenosis remains a subject of extensive debate. Several international societies and associations have published guidelines for the management of carotid patients. Although these recommendations are based on the same randomized trials, differences in interpretation of available knowledge have often led to different (or even conflicting) recommendations. This special report summarizes the current evidence-based optimal management of patients with symptomatic and asymptomatic carotid stenosis and compares key international guidelines. Finally, issues requiring further research are identified and discussed.