Stroke is the third most common cause of death worldwide following ischemic heart disease and cancer and the number one condition associated with permanent disability. In Western countries, the yearly incidence of stroke is ∼ 0.2% of the population and the number of stroke-related death is expected to double over the next 30 years. Studies from the Netherlands and Scotland showed that stroke accounted for 3% to 5% of their total health care resources. For 2006, the estimated direct and indirect cost of stroke in the United States was ∼ 60 billion. Significant stenosis of the internal carotid artery is responsible for 10% to 20% of all strokes or transient ischemic attacks. Large-scale randomized clinical trials have established the superiority of carotid endarterectomy (CEA) over medical management in patients with high-grade stenosis of the internal carotid artery, particularly among symptomatic patients. Although percutaneous carotid revascularization has been performed since the early eighties, the enthusiasm has long been tempered by the fear of cerebral embolism. Following the introduction of emboli protection devices (EPD) around the year 2000, the number of procedures performed worldwide has grown exponentially. We review the available studies on carotid stenting and discuss appropriate use of this procedure. Emphasis is also placed on optimal long-term pharmacotherapy in patients with carotid stenosis.