Significant technical advances have made carotid artery stenting an option for high-risk patients. These advances bring forth new challenges that must be overcome. Preprocedural planning is essential for optimal outcome for every patient given the high risk for significant neurologic complications. In this article we describe a standard approach for performing carotid artery stenting and techniques used to circumvent challenges that may be encountered. In addition, implementation of modifications and advanced techniques in challenging cases may allow successful treatment of carotid stenosis. Maintenance of proficiency in carotid artery stenting requires significant and ongoing experience.