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The relative role of surgical or endovascular treatment in carotid stenosis remains controversial. Results of recent studies add even more confusion to the debate. Major clinical trials so far have shown a wide range of complication rates for carotid endarterectomy and carotid stenting. Only surgeons or interventionists who can maintain a complication rate of 3 % or below should consider treating patients with asymptomatic disease. The relative role of surgical or endovascular treatment in carotid stenosis remains controversial. Results of recent studies add even more confusion to the debate. This article represents a simplified view from a surgeon who performs both surgery and endovascular treatment for carotid disease. The role of carotid endarterectomy in sympto-matic carotid stenosis has been well established by randomised control trials. For patients with symp-tomatic atherosclerotic carotid stenosis greater than 70%, as defined using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, the value of carotid endarter-ectomy (CEA) has been clearly established from the results of the NASCET and the European Carotid Surgery Trial (ECST).1 2 In NASCET, the estimate of any ipsilateral stroke at 2 years for this group of patients with high-grade stenosis was 26 % in the medical arm and 9 % in the surgical arm. For symptomatic carotid stenosis in the moderate category (50 % to 69 % stenosis), NASCET and ECST demonstrated significant benefits for CEA compared with medical therapy. In NASCET, the 5-year risk of ipsilateral stroke over the 5-year period was 22.2 % in the medically treated group and 15.7 % in patients treated surgically.3 The surgical complication rate was kept below 6 % in these trials. For patients with carotid stenosis below 50%, these trials showed that there was no significant benefit with surgery. For asymptomatic carotid stenosis greater than 60%, the margin of benefit for CEA compared with best medical therapy was statistically significant in two large randomised trials, although it was highly dependent on the low surgical complication rate o