This chapter reviews the major clinical trials on carotid endarterectomy and carotid angioplasty, and summarizes the technique used by the authors for carotid endarterectomy. The evolution of carotid endarterectomy, carotid angioplasty, and stenting and extracranial-intracranial (EC-IC) has been predicated on the results of clinical trials. The EC-IC bypass trial introduced the concept of multicenter prospective randomized trials to the neurosurgical community. The ongoing carotid revascularization endarterectomy versus stent trial (CREST) is prospectively randomizing patients with symptomatic carotid stenosis to either carotid endarterectomy or carotid angioplasty, and stenting with distal embolic protection (DEP), regardless of perioperative risk stratification. Assessing perioperative risk is essential in the evaluation of patients in whom carotid endarterectomy, carotid angioplasty and stenting or EC-IC bypass is being considered. Patients with symptomatic carotid occlusions may benefit from EC-IC revascularization provided they suffer from diminished cerebrovascular reserve.