The management of carotid artery disease has been carefully scrutinized over the past thirty years. The choice of surgery as compared to stenting for carotid disease has become more controversial with the recent data published from the CREST trial in the United States. The results from CREST can be interpreted in different ways, but I believe it has justified the efficacy and safety of carotid endarterectomy (CEA). This finding is especially true in older patients. The original clinical trials from the 1980’s and 1990’s (e.g. NACET and ACAS) demonstrated the value of carotid endarterectomy as compared to medical management in preventing TIA and stroke. The limitation of medical management at the time of publication of these trials was that aspirin alone was utilized as the sole agent in the majority of these studies. Our “medicine cabinet” has becomemuch more diversified and a combination of aspirin, Plavix, statin agents, b-blockers, and other medications are now readily available that assist in TIA and stroke prevention in patients with carotid artery disease. In light of the changes in the available “best” medical therapy, the results of the earlier clinical trials have been questioned. Many people have suggested that the carotid artery surgery trials need to be repeated with the current available medications