Carotid endarterectomy (CEA) has long been considered the "gold standard" in the treatment of patients with symptomatic or asymptomatic carotid stenosis. However, the utility of this treatment modality in medical or surgical "high-risk" patients remains in question. Numerous clinical trials have demonstrated that carotid angioplasty and stenting (CAS) is not inferior to CEA. Furthermore, there are also increasing data that show that best medical therapy is becoming more effective in preventing strokes and in a more cost-effective manner than carotid interventions. With this in mind, there is now ample evidence to suggest that in a certain subgroup of patients, CEA may not be indicated, and in fact, CAS or observation with best medical therapy is preferred.