More than 100 years of carotid artery surgery brought significant technical changes and even more relevant improvements in decision-making in symptomatic and also asymptomatic patients. Carotid endarterectomy with patch plasty or performed as eversion endarterectomy remained the standard procedure since DeBakey and Eastcott in the 1950s. The efficacy and safety of carotid endarterectomy in stroke prevention in patients with symptomatic stenosis of the internal carotid artery was proven by two large randomized trials in the 1990s and is valid ever since. Patients with symptomatic carotid near occlusion, however, were excluded from most trials. This lack in evidence and the strikingly low stroke rate under best medical treatment (BMT) only in these patients make the indication for revascularization quite controversial. Another matter of debate over the last years was the timing of treatment in symptomatic patients. Against the initial hypothesis that early revascularization carries a high risk of periprocedural complications, nowadays literature proves the safety of surgery in the first days after symptom onset. In contrast to that revascularization of an extracranial carotid stenosis after intravenous thrombolysis for intracranial occlusion needs to be postponed for at least 6–7 days to provide the accepted perioperative stroke rate of 6%. Best medical treatment reduced the natural stroke risk from a carotid artery stenosis to below 2% per year. Thereby the need of revascularization in clinically asymptomatic patients was more and more questioned. It seems meanwhile crucial to identify the patient at high risk for a stroke under BMT only. Morphological and clinical parameters are available to allow a risk stratification and distinguish between vulnerable and stable plaque.