Earlier trials comparing transfemoral carotid artery stenting (TF-CAS) with carotid endarterectomy (CEA) for asymptomatic carotid stenosis reported that the periprocedural (30-day) stroke or death rate is higher for TF-CAS, while long-term outcomes are similar. In the recent ACST-2 trial, the periprocedural rate of death or any stroke was slightly higher with TF-CAS compared with CEA, but the difference was not statistically significant. This result largely reflected a higher incidence of nondisabling stroke in the TF-CAS group. The five-year rate of periprocedural death or any fatal or disabling stroke was similar for TF-CAS and CEA (3.3 versus 3.5 percent). For medically stable individuals with asymptomatic carotid stenosis of 70 to 99 percent, we advise a shared decision-making approach; either intensive medical therapy alone or intensive medical therapy plus revascularization with CEA are reasonable treatment options. For those with an unacceptably high surgical risk with suitable anatomy, carotid artery stenting is an alternative.