In the 1980s, a series of landmark clinical trials in Europe and North America were undertaken that compared “best medical therapy” with carotid endarterectomy for both symptomatic and asymptomatic carotid stenosis and solidified the role of carotid endarterectomy for severe bifurcation atheroma. However, these conclusions were not accepted without reservation by some. A number of neurologists remained, and still remain, highly skeptical of the role of endarterectomy in the neurologically asymptomatic patient. At the same time there were those who questioned the efficacy of endarterectomy in patients who were not eligible for the controlled trials. Since the publication of those trials, progress has been made in both medical and surgical management of patients with carotid stenosis and a new therapy, carotid angioplasty with stenting, has emerged as an alternative to endarterectomy. Over the past 5 years there has been a voluminous literature, including the recently published CREST study, on outcomes of contemporary carotid endarterectomy, carotid stenting, and medical management of extracranial carotid stenosis. The last decade has seen the emergence of carotid stenting as an alternative to endarterectomy, along with a large number of clinical trials comparing the two modalities. This issue of Perspectives in Vascular Surgery and Endovascular Therapy focuses on the indications for both carotid endarterectomy and carotid stenting in managing carotid bifurcation stenosis. It is most likely that these 2 modalities will emerge as complementary rather than competitive alternatives for stroke prevention. Dr Joseph Ricotta opens our issue with an approach that matches the treatment decision to the patient. Dr Cao and his group succinctly summarized the results of stenting trials, along with the questions left unanswered. Drs Chung and Faries provide an analysis of the current and future role of carotid stenting based on results available from the literature. The efficacy of carotid interventions, open or endovascular, is critically dependent on minimizing complications associated with the procedure. The final articles of the issue provide suggestions that will minimize the complications of carotid stenting and carotid endarterectomy and maximize the effectiveness of each technique. Management of extracranial carotid disease to prevent stroke remains a multifaceted exercise. Both pharmacologic and interventional approaches continue to be refined and evaluated. An emerging consensus suggests that optimal management must be tailored to the particular clinical scenario. We hope that this issue of Perspectives will be a resource for those clinicians who treat patients with occlusive disease of the carotid bifurcation.