Carotid revascularization procedures remain a cornerstone of vascular surgery practice, with approximately 100,000 carotid revascularization procedures performed annually in the US.1 Since the first carotid endarterectomy (CEA) in 1953 by Dr. Michael DeBakey, the therapeutic landscape has evolved with advances in both surgical technology and care delivery.2 The landmark North American Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) showed strong benefits of CEA in symptomatic patients compared to medical management.3,4 However, it became evident that there were limited options for patients who were not candidates for open surgical repair who otherwise may benefit from revascularization. As such, transfemoral carotid artery stenting (tfCAS), was first introduced by Roubin, Yadav, and others in the 1990s and demonstrated noninferiority to CEA in high-risk surgical patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial in 2004.5 Subsequent studies have raised concerns about the safety and efficacy of tfCAS. Though these studies demonstrated a lower perioperative myocardial infarction (MI) rate, they note perioperative stroke rates after tfCAS to be double that after CEA.[6], [7], [8], [9] Transcarotid artery revascularization (TCAR) was introduced in 2012, which incorporated a flow reversal neuroprotection system to mitigate the risks of stroke.[10], [11], [12] After the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) trial reported low rates of major adverse events after TCAR in high-risk patients, the FDA approved its use in high-risk patients in 2015 and in standard-risk patients in 2022.11,13

In October 2023, the Centers for Medicare and Medicaid Services (CMS) further expanded its coverage for carotid artery stenting to standard risk patients.14 Despite a wealth of clinical trials, meta-analyses, and observational studies, the optimal approach to carotid revascularization remains an ongoing debate. Conflicting data regarding efficacy, durability, and perioperative risk continue to challenge consensus especially in asymptomatic carotid artery stenosis. Accordingly, the purpose of this review is to critically evaluate the current literature surrounding optimal surgical management of carotid artery stenosis.