The management of carotid bifurcation disease continues to evolve. Carotid endarterectomy remains the gold standard for symptomatic patients, and for selected asymptomatic patients who have hemodynamically significant carotid stenosis. Medical management of the high-risk plaque has continued to improve and is complementary to carotid endarterectomy. Carotid angioplasty and stenting is presently being evaluated as a treatment option for high-risk patients. This article reviews the current understanding of disease management.