Patients with symptomatic carotid artery disease should be managed by a multidisciplinary team including neurologists, vascular surgeons and interventionalists. Duplex ultrasound is the most widely used diagnostic modality to assess carotid disease, followed by additional imaging tests (CT- or MR-angiography) to confirm the severity of the stenosis, detect brain lesions, and assess intracranial circulation as well as the supra-aortic anatomy. Although overall randomized trial results favored (CEA) over carotid artery stenting (CAS) in symptomatic patients, this was likely related to the insufficient expertise of the endovascular specialists in several of the trials. CAS should be considered as a valid alternative to CEA in patients with favorable anatomy and in those at high-surgical risk, provided it is performed by experienced operators in high volume centers. Under those circumstances, it is reasonable to offer the patients the two options (CEA or CAS) after description of pros and cons of each therapy. CAS results may be further improved by better patient selection, new techniques, and technology advancements.