Carotid stenosis is frequent in the general population, especially in elderly people and is associated with a high
risk of stroke and vascular events. In patients with asymptomatic carotid stenosis the overall annual risk of ipsilateral
stroke has dramatically decreased over the past decades, due to improvement in medical management. Asymptomatic carotid
stenosis is probably a better indicator of generalized atherosclerotic disease than of stroke risk, with an average risk
of nonstroke death (mainly due to ischemic heart disease) generally higher than the risk of ipsilateral stroke. Management
of risk factors, antiplatelet therapy, and statins are highly beneficial in these patients. Carotid surgery in patients with asymptomatic
carotid stenosis is associated with a small absolute benefit compared to medical treatment. The prognosis of
patients with symptomatic carotid stenosis is dramatically different from that of patients with asymptomatic carotid
stenosis because the risk of stroke on medical treatment alone is very high and highest during the first few days and
weeks. In these patients, endarterectomy is highly beneficial and the absolute benefit of is increased in patients with 70–
99% stenosis, men, patients over 75 years, and in those treated within 2 weeks after the last event. The meta-analysis of
the 3 major European trials comparing endarterectomy to stenting in symptomatic stenosis has shown an increased risk of
perioperative risk of any stroke or death in the stenting group (74% increase in risk in patients treated with stenting).
However, the risk of stroke or death after stenting and surgery were equivalent below the age of 70 whereas there was a
two-fold increase in risk of stenting over endarterectomy above this age. Thus, surgery remains the first line method in
most cases but stenting is potentially an alternative in young patients.