Two major randomised trials concerning the surgical treatment of carotid artery stenosis showed that carotid endarterectomy is superior to medical treatment in reducing the overall risk of stroke in symptomatic or asymptomatic patients.w1–4 The first phase of the North American endarterectomy trial (NASCET)w1 confirmed the superiority for symptomatic severe (lumen diameter reduction > 70%) carotid stenoses while the second phase of the NASCET trial showed the benefit of carotid endarterectomy in patients with symptomatic moderate stenosis (50–70%).w4 The asymptomatic carotid study (ACAS) showed a reduction in stroke rate after carotid endarterectomy also in asymptomatic patients with carotid stenoses > 60%.w2 Although carotid endarterectomy is nowadays considered the gold standard for the treatment of carotid occlusive disease, the approach is not without complications. In the NASCET study population, 5.8% of patients suffered from perioperative death and stroke. When the attention is focused on routine clinical practice without strict patient selection criteria, or if a neurological audit is performed by independent neurologists, the incidence of major events can easily double.1 Since the first percutaneous transluminal carotid angioplasty was performed by Kerber in 1980,w5 the rapid improvement in interventional technology and materials has transformed a technique initially developed as a palliative treatment in inoperable patients into a therapeutic alternative option to surgery.w6–9 The main concern has always been the safety of such intervention in terms of cerebral embolisation, a frequent event during the procedure detected by transcranial Doppler monitoring, diffusion weighted magnetic resonance, and retinal fluoangioscopy even in asymptomatic patients.w10 w11 This may be explained by the presence of thrombotic material in carotid plaques frequently observed during surgical exploration.w12 Preliminary studies evaluating the safety and efficacy of carotid angioplasty showed a higher incidence of stroke and death compared to carotid endarterectomy.w7 w13–15 One …