Carotid artery stenosis is a major cause of ischemic stroke, with carotid endarterectomy (CEA) and carotid artery stenting (CAS) as primary revascularization options. CEA, established as the gold standard through landmark trials such as NASCET and ECST, offers substantial stroke risk reduction in symptomatic high-grade stenosis and more modest benefit in selected asymptomatic patients. CAS emerged in the late twentieth century as a less invasive alternative, with randomized controlled trials (e.g., CREST, ICSS, EVA-3S, SPACE) demonstrating comparable long-term efficacy but differing perioperative risk profiles—CAS carries higher early stroke risk, especially in older patients, whereas CEA is associated with higher myocardial infarction and cranial nerve injury rates. Patient selection depends on symptom status, degree of stenosis, age, comorbidities, and anatomical factors, with guidelines favoring CEA for most low-surgical-risk patients and reserving CAS for high-surgical-risk or anatomically challenging cases. Technological advances—including embolic protection devices, mesh-covered stents, and transcarotid artery revascularization (TCAR)—have improved CAS safety, while refinements such as eversion CEA, minimally invasive approaches, and patch angioplasty enhance CEA outcomes. Ongoing trials (CREST-2, ECST-2, SPACE-2) and improved medical therapy are reshaping the role of revascularization, particularly in asymptomatic stenosis. Current evidence supports CEA as the preferred option for low-risk symptomatic patients, ideally within 2–14 days of ischemic symptoms, while emphasizing individualized decision-making for moderate-to-high surgical risk patients. Intensive medical management remains essential for all patients, and future evidence may further refine optimal strategies for balancing procedural risks with long-term stroke prevention.