Angioplasty and stenting should not be performed for patients with asymptomatic atherosclerotic carotid bifurcation stenosis, except in the context of randomized clinical trials. Surgical carotid endarterectomy (CEA) has been proven effective over medical therapy in select asymptomatic patient populations. The benefit in these patients is small and easily overcome by procedural complication rates over 3%, owing to the relatively low risk for stroke on medical therapy. Until a randomized controlled clinical trial demonstrates reasonable equivalence of carotid angioplasty and stenting (CAS) to CEA for stroke risk reduction in asymptomatic low-surgical risk patients, there is no rationale for its use in this setting. Furthermore, there is no evidence that revascularization by either CEA or CAS is superior to medical therapy for patients that are not good surgical candidates owing to medical comorbidities or anatomic factors. Randomized trials in this high surgical risk patient population must include a medical treatment arm. In this article, we will review the existing data for CAS in patients with asymptomatic atherosclerotic carotid artery stenosis.