Stroke is the third leading cause of death and the most common cause of long-term disability in the USA. Approximately 25% of strokes are due to carotid artery disease. The mechanisms of stroke include thrombotic occlusion, thrombus embolism, atheroembolism and dissection or subintimal hematoma. Today, endarterectomy is the standard of care for management of significant carotid artery disease. The SAPPHIRE trial has proved the noninferiority of carotid artery stenting versus carotid endarterectomy in 'high-risk' patients, which led to the US FDA approval of carotid stent for high-risk patients. The CREST trial is the largest randomized trial comparing stenting versus endarterectomy and showed no significant difference in death, stroke or myocardial infarction. Over the last 15 years, the accumulation of experience, the improvement of stent platforms and embolic protection devices, and the strong demand from patients for a less invasive alternative to carotid endarterectomy has made carotid artery stenting an equally efficient and safe procedure for the prevention of stroke.