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Diagnosis and management of carotid arterial occlusive disease and its ensuing comorbid illnesses have been the focus of extensive debate during the past two decades. The development of sophisticated ultrasound technology has enabled us to objectively define the severity of carotid stenosis in regions commonly accountable for stroke. Results from several well-designed prospective randomized trials have enhanced our understanding of the epidemiology of this disease and have guided our judgment with regard to aggressive diagnosis and intervention. As clinicians, we have been charged to address underlying risk factors, including hyperlipidemia and smoking abuse, as well as concomitant coronary, renal, and lower extremity artery disease. Carotid endarterectomy coupled with optimal medical management is superior to medical management alone in asymptomatic patients with high-grade carotid stenosis (> 70% diameter reduction) and recently has been shown to have value for symptomatic patients with stenosis of 50% to 69%.