Carotid artery stenting has emerged as an alternative to carotid endarterectomy for the treatment of severe extracranial carotid stenosis in patients with anatomic or clinical factors that increase their risk of complications with surgery, yet there remains a substantial amount of variability and uncertainty in clinical practice in the referral of patients for stenting vs endarterectomy. By undertaking a thorough review of the literature, we sought to better define which subsets of patients with "high-risk" features would be likely to preferentially benefit from carotid stenting or carotid endarterectomy. Although only a single randomized trial comparing the outcomes of carotid stenting with distal protection and endarterectomy has been completed, a wealth of observational data was reviewed. Relative to endarterectomy, the results of carotid stenting seem favorable in the setting of several anatomic conditions that render surgery technically difficult, such as restenosis after prior endarterectomy, prior radical neck surgery, and previous radiation therapy involving the neck. The results of stenting are also favorable among patients with severe concomitant cardiac disease. Carotid endarterectomy, alternatively, seems to represent the procedure of choice among patients 80 years of age or older in the absence of other high-risk features. Overall, existing data support the concept that carotid stenting and endarterectomy represent complementary rather than competing modes of therapy. Pending the availability of randomized trial data to help guide procedural selection, which is likely many years away, an objective understanding of existing data is valuable to help select the optimal mode of revascularization therapy for patients with severe carotid artery disease who are at heightened surgical risk.