As operator experience and device technology continue to improve, the theoretic advantages of endovascular approaches to treat carotid occlusive disease may be closer to realization. Currently, data from controlled trials of CAS is minimal, but several multicenter RCTs comparing CAS to CEA are recruiting patients actively and preliminary results show procedural morbidity and mortality rates for CAS that compare favorably to CEA. Community-based experience with CAS continues to grow and further refinements in patient selection based on plaque morphology and other variables offer further hope that endovascular approaches to carotid occlusive disease may benefit selected patients. Given the proved efficacy and durability of CEA for treatment of extracranial carotid stenosis, surgical revascularization remains the recommended standard of care for most patients. CAS will have to be proved equivalent or superior to surgery and as cost-effective to facilitate its widespread acceptance as a treatment alternative for carotid occlusive disease.