Stroke is currently one of the leading causes of death in China. It accounts for 20% of total deaths in urban areas and 19% in rural areas. Among stroke patients, the ratio of ischemic to hemorrhagic lesions is 4:1, and carotid stenosis is very closely related to ischemic diseases, especially stroke, and about 30% of ischemic strokes are caused by extracranial carotid stenosis. Extracranial carotid stenostic disease refers to stenosis and/or occlusion of the common and internal carotid arteries that can cause stroke and transient ischemic attacks. If left untreated, the 2-year stroke rate can be as high as 26% in patients with >70% symptomatic carotid stenosis. Carotid artery stenosis causes stroke mainly by the dislodgement of plaque or thrombus to form emboli that cause embolism of the intracranial arteries, which in turn causes ischemic cerebral infarction of the corresponding brain tissue. Therefore, the goal of treatment is to remove the lesion that can cause the embolus to dislodge or prevent it from dislodging. The treatment of carotid stenosis includes 2 aspects: surgical treatment and pharmacological treatment. Surgical treatment mainly includes traditional carotid endarteretomy (CEA) and carotid artery angioplasty and stent placement (CAS), which has been widely performed in recent years. Because carotid artery surgery is a technically difficult and risky operation, the indications for the procedure must be strictly determined and observed in order to obtain good surgical results and reduce the incidence of perioperative complications. The current clinical indications for CEA are based on the North American symptomatic carotid endarterectomy trial (NASCET), the European carotid surgery trial (ECST), and the degenerative carotid surgery trial (ECST). The results of large multicenter prospective randomized trials, including the North American symptomatic carotid endarterectomy trial (NASCET), the European carotid surgery trial (ECST), and the Veterans affairs cooperative symptomatic carotid stenosis trial (VACS), have been revised in light of recent developments. The results of large multicenter prospective randomized trials such as the Veterans affairs cooperative symptomatic carotid stenosis trial (VACS), with some modifications based on recent advances. The absolute indications for CEA are: one or more transient ischemic attacks with carotid stenosis R70% within 6 months; one or more mild non-disabling stroke attacks with symptoms or signs lasting more than 24h and carotid stenosis R70% within 6 months. In simple terms, the patient is symptomatic and has a stenosis of R70%. Relative indications for CEA: asymptomatic carotid stenosis R70%; symptomatic stenosis in the range of 50-69%, asymptomatic carotid stenosis <70%, but angiography or other tests suggesting an unstable stenotic lesion. It is also required that the total perioperative stroke incidence and mortality rate be <6% in symptomatic patients, and that the total perioperative stroke incidence and mortality rate be <3% in asymptomatic patients, with a patient life expectancy of >5 years [6,7]. Here, great emphasis is placed on whether the plaque is stable or not, because unstable plaques with less severe stenosis are still highly susceptible to dislodging and causing embolization of the corresponding vessels in the brain. Timing of CEA surgery: at present, we still recommend that surgery is safer in acute cerebral infarction after 6 weeks of onset, but for recent symptomatic episodes, surgery can be chosen within 2 weeks when imaging suggests an unstable plaque [8]; in case of bilateral lesions, the surgical interval between the two sides is at least 2 weeks, and the severe stenosis and/or symptomatic side is preferred; if the patient has complete occlusion of the carotid artery, it should be free of emboli to continue If the patient is completely occluded, surgery does not reduce the incidence of stroke and is therefore not recommended. The former requires a relatively low location of the carotid bifurcation. The latter does not require incision of the carotid sinus, avoids stenosis caused by longitudinal incision and suturing, and allows simultaneous shortening of the carotid artery in case of overgrowth. The incidence of postoperative restenosis is lower than that of the longitudinal incision, but it is not suitable for patients with calcific stenosis in the distal carotid artery and excessive carotid bifurcation [9]. In general, there is no significant difference in surgical results, and the specific choice of approach can be decided according to the patient’s specific situation and the operator’s quantitative degree, and does not have to be forced. In those with small carotid diameter, after performing a conventional longitudinal approach (internal diameter <4 mm), a patch can be added to prevent carotid narrowing. Most authors believe that the application of a diverter tube can reduce the intraoperative ischemic time in the cerebral hemisphere on the operative side. The specific indications for its application include: (i) imaging evidence suggesting preoperative stroke; (ii) complete occlusion of the contralateral internal carotid artery; (iii) carotid regurgitation pressure <50 mm Hg; (iv) those who cannot tolerate carotid block test intraoperatively; (v) those with abnormalities in intraoperative brain function tests; (vi) those with reduced cerebral blood flow on intraoperative transcranial TCD; and (vii) those with incomplete intracranial Willis ring compensation [10]. Endovascular treatment of carotid stenosis has undergone three stages of development, from simple balloon dilation, balloon dilation + stent implantation to the current stent implantation under cerebral protection, and its indications are also progressing. The current indications for CAS are based on the CAVATAS trial (The Carotidand Vertebral Artery Transluminal Angioplasty Study), the SAPPHIRE trial (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy trial), the EVA-3S trial (Endarterectomy Versus Stenting In Patients with Symptomatic Severe Carotid Stenosis), the SPACE trial (Stent-Protected Angioplasty Versus Carotid Endarterectomy In Symptomatic Patients), combined with results from trials such as NASCET and ECST [11,12 ,13,14]. Indications for CAS: symptomatic carotid stenosis >50%, requiring an incidence of stroke and death from all causes ≤6% within 30 days postoperatively in the previous year at the operator’s unit; and an incidence of disabling stroke or death ≤2%; asymptomatic carotid stenosis >60%, requiring an incidence of stroke and death from all causes ≤3% within 30 days postoperatively in the previous year at the operator’s unit; and an incidence of disabling stroke or The incidence of death should be ≤1% [15]. The choice of CEA or CAS for patients with carotid stenosis should be based not only on the operator’s proficiency (proficiency reduces the rate of perioperative complications), but also on the patient’s specific situation. CAS should be considered when the following conditions are present: 1. The patient has cardiovascular comorbidities: I. Congestive heart failure (New York Heart Association classification III/IV) and/or various known severe left heart insufficiency; II. Open heart surgery required within 6 weeks; III. Recent history of heart attack (within 4 weeks); IV. Unstable angina (Canadian Cardiovascular Society classification III/IV); V. contralateral carotid artery obstruction; VI. carotid artery stenosis secondary to myofiber dysplasia. 2. Patients with special conditions: I. contralateral recurrent laryngeal nerve palsy; II. history of neck radiotherapy or post-radical neck surgery; III. restenosis after CEA; IV. surgically difficult to visualize lesions, common carotid stenosis with high carotid bifurcation position/below the clavicular plane; V. severe pulmonary disease (COPD, FEV1 <20%); VI. Age > 80 years; VII. Patient refuses to undergo CEA. CAS requires the use of contrast agents and DSA machines due to the characteristics of its intravascular luminal operation, and there are corresponding contraindications. Relative contraindications to CAS: intracranial vascular malformations; subacute cerebral infarction; contraindications to angiography (severe contrast reactions, chronic renal failure); severe calcific lesions with difficult dilation. Absolute contraindications to CAS: intracarotid appendage thrombosis; lesions inaccessible by intraluminal methods (severe distortion of aortic arch branches, absence of a suitable introducer artery, special anatomy of the aortic arch); severe stenosis (>99%); lesions near carotid aneurysms. The embolization protected device (EPD) has been shown in clinical trials to significantly reduce the incidence of perioperative stroke; our current clinical follow-up results are similar: there is a significant difference in the incidence of perioperative stroke before and after EPD use, and we therefore recommend the routine use of EPD for CAS. patients with carotid stenosis, distal-think-through EPDs (including Filterwire and Angiogard, etc.) are recommended, and proximal-blocking types can be considered if the patient has severe carotid stenosis that cannot be passed through a distal-think-through EPD [17]. In patients with indications, surgical treatment can significantly reduce the incidence of stroke. However, the long-term outcome of surgery cannot be guaranteed without medication in internal medicine. The main drugs are oral antiplatelet aggregation drugs and statins. The main antiplatelet aggregation drugs commonly used are aspirin and clopidogrel. Aspirin is inexpensive and really effective, while clopidogrel is more effective but more expensive. Those with the condition can take it orally for a long time, but those without the condition can stop it after 3 months of overlap with aspirin and switch to aspirin alone. The significance of statins in postoperative treatment of carotid stenosis is not only to lower lipids, but also to stabilize plaque and prevent restenosis. Therefore, they should be routinely administered orally when available. Surgical treatment of carotid artery stenosis has been clinically proven to be effective for half a century. With the increase of morbidity in the country, the number of domestic carotid stenosis surgeries has been increasing year by year. In order to obtain good treatment results, clinicians must be familiar with the pathophysiology of carotid stenosis and strictly comply with the indications for surgery. Through continuous clinical practice, the treatment level of carotid artery stenosis in China will be improved.