The NASCET showed that stroke risk was significantly reduced by carotid surgery in suitable patients with recent symptoms and carotid stenosis narrowing the vessel by more than 70%. For asymptomatic stenosis the risks and benefits of surgery are finely balanced and two recent trials, the asymptomatic carotid atherosclerosis study (ACAS) trial and the recent Medical Research Council (MRC) asymptomatic carotid surgery trial (ACST) have looked at this in great detail. Two new trials are in the process of commencing: the asymptomatic carotid surgery trial II (ACST II), and also the transatlantic asymptomatic carotid interventional trial (TACIT). Data on carotid angioplasty available from several small series show the risks of procedural related stroke or death are similar to those reported in NASCET and ECST. Carotid stenting is now a mature technique and is being rapidly used by many centers as a first-line treatment for symptomatic and asymptomatic carotid stenosis.