Background <p>Atherosclerotic carotid artery stenosis is a major contributor to ischemic stroke. Conventional Doppler ultrasound is widely used for screening and grading, but diagnostic performance is constrained by angle dependence and limited capability to characterize complex, non-laminar flow or to derive hemodynamic metrics such as wall shear stress (WSS).</p> Objective and key findings <p>This review summarizes current evidence on ultrasound vector flow imaging (VFI) in carotid atherosclerotic disease, focusing on key technical approaches and clinical applications. By estimating at least two in-plane velocity components, VFI provides angle-independent velocity vectors and multidirectional flow visualization, most commonly implemented using transverse oscillation or multi-angle plane-wave imaging. In vitro studies and small, single-center cohorts suggest that VFI-derived peak systolic velocity (PSV) agrees with angiographic or MR references and may be less error-prone than pulsed-wave Doppler in disturbed flow. VFI also enables estimation of wall shear stress (WSS) and flow-disturbance metrics (e.g., turbulence indices), which have been associated with stenosis severity and plaque features such as ulceration or intraplaque neovascularization. However, evidence remains largely cross-sectional and frequently two-dimensional, and measurements may be affected by vendor-specific processing, imaging depth, and signal dropout in heavily calcified or tortuous vessels.</p> Conclusion <p>VFI is a promising noninvasive adjunct to carotid ultrasound that may extend hemodynamic assessment beyond conventional Doppler, particularly in complex anatomy. Prospective multicenter validation with standardized acquisition/reporting and quality control is needed to define reproducible thresholds and incremental clinical utility; the roles of three-dimensional VFI and AI-enabled automation remain to be established.</p>