Randomized clinical trials have demonstrated that carotid endarterectomy (CEA) is superior to medical management for stroke prevention in patients with symptomatic and, to a lesser degree, asymptomatic internal carotid artery stenosis. However, large-scale registries have shown that the adverse event rates following CEA are commonly higher than observed in the trials. In the last decade, carotid artery stenting (CAS) has emerged as a less invasive alternative to surgery. In order to address the efficacy of CAS, we performed a meta-analysis of 10 randomized trials comparing CAS with CEA in 4648 mainly symptomatic patients. The analysis showed that CAS was associated with a statistically significant increased death or stroke rate at 30 days compared with CEA (odds ratio 1.60, 95% confidence interval 1.26-2.02). However, most of the trials had inadequate requirements in terms of endovascular expertise and did not mandate the use of emboli protection devices. Beyond 30 days, long-term follow-up of the trials previously reported suggest that both revascularization techniques are equivalent in terms of stroke prevention. Conversely, large-scale high-quality CAS registries--mostly with independent neurological assessment and clinical event committee adjudication--have reported results in the range of current recommendation for CEA in over 20 000 patients, despite the fact that the majority of patients were at high risk for surgery. Until further data become available, the performance of CAS should be limited to protocols or centres of excellence and targeted especially to patients at high risk for surgery.