Carotid artery disease is a major cause of stroke. Carotid endarterectomy when performed with a low complication rate in patients with severe lesions has been shown to reduce the subsequent risk of stroke in a series of randomised controlled trials in both symptomatic and asymptomatic populations. The CAVATAS trial demonstrated that simple balloon angioplasty of carotid stenoses was as good as endarterectomy in terms of stroke prevention and was associated with a lower complication rate. Carotid stenting performed with the use of distal protection devices has been shown to be superior to endarterectomy in patients considered to be at increased perioperative risk as assessed by a variety of clinical and angiographic parameters. Comparisons of carotid stenting and endarterectomy in patients considered to be of normal perioperative risk are ongoing. Optimal medical therapy is mandatory for all patients with carotid artery disease.